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ANEMIA 


ALSO  NOW  READY 

AN   ATLAS   OF   HEMATOLOGY 

With  a  Description  of  the  Technique  of  Blood  Examination. 
By  Dr.  Karl  Schleip,  Scientific  Assistant  in  the  Medical  Clinic, 
University  of  Freiburg  i/B.  English  Adaptation  of  Text  by 
Frederic  E.  Sondern,  M.D.,  Professor  of  Clinical  Pathology, 
New  York  Post-Graduate  Medical  School  and  Hospital,  etc. 
Large  Crown  4to,  with  71  Coloured  Illustrations,  remarkable 
for  exceptional  accuracy  and  beauty  of  detail.  \  Leather,  price 
$10*00  net. 

New  York:   REBMAN   COMPANY,   Publishers 


A  N  it]  M  I  A 

BY 

GEH.    OBERMEDIZINALRAT    PROFESSOR 

Dr.    p.    EHRLICH 

DIRECTOU  OF  THK  KONIGI..   INSIITUT  I'UK  EXI'KRF  MENTKI.I.K  THKKAI'IK,   I'RANKFURT  A.-.M. 

AND 

Dr.    a.    LAZARUS 

PNOKESSOR    OF   THE    UNIVEHSI'IV   OK    DEKI.IN-CHARI.OTTIiNBUKO 

PART  I.     VOLUME  1. 

NORMALand  PATHOLOGICAL  HISTOLOGY 
OF  THE  BLOOD 

SECOND  EDITION 
{enlarged  and  to  a  great  extent  rewritten) 


Dr.  a.  LAZARUS       ,,,       Dr.   O.  NAEGELI 

AND 
PROFESSOR  (bERLIn)  PRIVAT-D02ENT  (zURICh) 


TRANSLATED    FROM    THE    GERMAN    BY 

H.  W.  ARMIT,  M.R.C.S.,  L.R.C.P.(London) 

WITH    5   ILLUSTRATIONS   IN   THE  TEXT  AND   5   COLOURED    PLATES 


■^^^ 


NEW    YORK 
REBMAN     COMPANY 

1123     BROADWAY 


Ail  Kiirhts  Eeserved 


PREFACE  TO  THE  SECOND  GERMAN 
EDITION 

It  is  now  more  than  ten  years  since  I,  together  with  my 
pupil,  A.  Lazarus,  published  the  First  Edition  of  tJiis  part  of 
Ancemia.  Apart  from  a  critical  description  of  general  clinical 
methods  of  examination,  it  dealt  with  the  position  at  that  time 
of  the  normal  and  pathological  histology  of  the  blood.  It  was, 
moreover,  intended  that  this  book  should  be  especially  devoted  to 
a  resume  of  the  various  works  published  by  me  and  my  pupils,  as 
well  as  the  hitherto  unpublished  results  of  my  investigations  and 
the  views  which  I  had  adopted  on  the  basis  of  these  results. 

A  glance  over  the  hematological  literature  of  the  last  ten 
years — a  literature  which  has  assumed  almost  immeasurable 
dimensions — shows  that  our  Ancemia  has  stimulated  investigation 
widely  and  has  influenced  it.  The  large  majority  of  the  com- 
munications have  dealt  with  the  problems  which  have  been 
discussed  in  our  book,  and  while  some  of  these  works  support 
the  views  set  forth,  others  oppose  them.  Histologists  as  well  as 
clinicians  have  taken  a  very  lively  part  in  this  criticism. 

It  has  been  of  the  greatest  satisfaction  to  me  that  my  seed 
has  fallen  on  such  fruitful  soil ;  but  it  is  especially  pleasant  for 
me  to  find  that,  after  the  completion  of  these  ten  years,  the  views 
which  I  have  from  the  first  defended  as  the  foundation  of  modern 
cellular  hfematology,  in  spite  of  the  opposition  of  many  renowned 
observers,  have  been  more  and  more  acknowledged,  and  I  am 
convinced  that  within  a  very  short  space  of  time  absolute 
unanimity  with  regard  to  these  questions  will  reign  among 
haematologists,  as  far  as  the  principles  are  concerned,  in  concord 
with  my  doctrines.     It  is  true  that  more  recent  work  has  removed 

V 


VI 


PREFACE 


many  a  stone  from  the  building  which  I  had  erected,  but,  on  the 
other  hand,  this  same  work  has  materially  assisted  in  the 
completion  of  >the  structure.  The  foundation,  however,  has  not 
been  touched  in  any  important  detail. 

This  refers  more  especially  to  my  doctrine  of  the  anaemic 
conditions,  which  I  have  grouped  according  to  the  form  of  reaction 
of  the  bone  marrow  and  to  the  doctrine  of  dualism  of  the  white 
blood  cells,  which  I  have  held  from  the  very  first.  It  is  just 
with  regard  to  this  subject  that  many  of  my  earlier  pieces  of 
evidence  have  been  disproved  by  recent  researches,  and  in  many 
important  details  this  question  has  assumed  another  aspect  to 
that  which  it  presented  ten  years  ago.  It  is,  however,  with  great 
satisfaction  that  I  note  from  the  recent  literature,  and  particularly 
from  the  Transactions  of  the  "  Meeting  of  Scientists  and  Physic- 
ians," held  in  Cologne  in  1908,  that  unanimity  has  been  arrived 
at  with  regard  to  the  chief  points,  and  that  the  "  unitarians  "  seem 
to  have  withdrawn  from  the  fight. 

It  appears  to  be  generally  accepted  now  that  the  various 
granules  of  the  cells  must  be  regarded  as  products  of  specific 
metabolism.  This  has  been  demonstrated  more  especially  in  the 
more  recent  publications.  In  this  connection  the  observations, 
for  example,  of  Kollmann  are  very  important.  He  showed  that 
in  the  lower  animals  {e.g.  the  crab),  a  disappearance  of  the 
granules  can  be  obtained  by  starvation.  This  observation  may 
be  able  to  throw  much  light  on  phenomena  of  human  pathology 
in  which  the  neutrophile  cells  have  lost  their  granules  either 
completely  or  in  part.  I  have  described  this  in  a  case  of  anaemia. 
Similar  conditions  have  been  met  with  in  leukaemia,  and  the 
appearances  of  the  blood  in  these  cases  have  in  many  instances 
led  to  erroneous  suppositions  with  regard  to  the  genesis  of  the 
white  blood  corpuscles.  If  I  might  express  a  wish  for  the  future, 
it  would  be  that  physiological  chemistry  should  attempt  to  clear 
up  the  chemical  nature  of  the  granules,  since  it  is  possible  that 
the  substances  involved  might  turn  out  to  be  of  great  interest  for 
clinical,  therapeutic  purposes. 

During  the  last  five  years  we  have  been  pressed  both  by  our 


PREIACK  vii 

publishers  and  by  our  leadeiH  to  edit  a  new  edition  of  Ancemia, 
but  in  view  of  the  large  number  of  questioriB  which  were  still 
being  discussed  with  energy,  this  was  postponed — much,  it  must 
be  admitted,  against  our  desires.  Pressing  obligations  have 
prevented  me  from  taking  part  in  the  preparation  of  this  Second 
Edition,  and  for  this  reason  I  have  requested  Privat-Dozent  Dr. 
0.  Naegeli  of  Zurich  to  utilize  his  well-known  capabilities  in 
assisting  my  original  co-operator, — A.  Lazarus, — to  undertake  the 
work. 


P.  EHRLICH. 


Frankfurt-am-Main, 
April  1909. 


PREFACE  TO  THE  ENGLISH  EDITION 

The  name  of  Ehrlich  conveys  two  ideas  directly  to  the  mind  of 
the  ordinary  student  of  medicine  in  England  :  blood  and  immunity. 
Of  these  two  ideas,  that  of  blood  is  the  clearer  in  the  mind  of  the 
average  practitioner,  because  the  teaching  of  the  great  German 
savant  has  reached  him  with  more  facility  and  in  greater  detail 
with  regard  to  the  histology  of  the  blood  than  with  regard  to  the 
intricacies  of  the  mechanisms  of  side  chains  and  antibodies. 

The  name  of  Ehrlich  is  one  which  the  English  htematologist 
and  the  English  research  student  has  learned  to  value,  and  one 
which  he  cannot  regard  as  Teutonic ;  he  claims  it  as  an  inter- 
national name. 

In  introducing  a  work  which  has  emanated  from  Ehrlich's 
school,  and  which  in  its  first  edition  was  in  part  written  by 
Ehrlich  himself,  to  the  medical  profession  in  England,  no  need 
exists  for  any  recommendation  of  the  author's.  The  value  of  the 
teaching  of  the  greatest  medico-biologist  must  be  recognised  by 
everyone. 

The  task  of  transferring  the  ideas  of  the  authors  into  a 
readable  form  of  English  has  been  one  which  the  translator  has 
willingly  attempted,  because  he  holds  the  opinion  that  it  will  be 
of  use  to  the  medical  profession  in  this  country  to  have  at  its 
disposal  a  work  which  aims  chiefly  at  defending  the  manifold 
doctrines  which  Ehrlich  has  introduced  in  htematology.  Some  of 
the  views  put  forward  may  not  be  as  widely  accepted  as  the  one 
author  (Dr.  0.  Naegeli)  would  have  the  reader  believe,  but  no 
attempt  has  been  made  to  introduce  any  outside  opinions  into  the 
work.     It  has  been  left  entirely  Ehrlichian. 

The    extraordinary   application    of    intra-cellular    chemistry 

ix 


X  PREFACE 

which  characterises  Ehrhch's  blood  work  is  well  set  forth  in  the 
pages  of  this  book,  and  much  of  the  material  dealt  with  must  be 
regarded  as  the,  result  of  genius  working  against  the  disadvan- 
tages of  almost  complete  ignorance. 

It  is  the  earnest  wish  of  the  translator  that  his  attempts  to 
present  Ehrlich's  and  Lazarus'  Aoicemia  in  a  readable  form  to 
the  British  medical  practitioner  has  succeeded,  and  that  the 
English  Edition  may  find  the  favour  which  the  original  edition 

undoubtedly  enjoys. 

H.  W.  ARMIT. 

LoNDOK',  June  1910. 


TABLE  OF  CONTENTS 


Peepace  to  Second  German  Edition,  by  P.  Ehklicu 
Peeface  to  the  English  Edition  (The  Teanslatoe) 


Definition- 


chapter  I 

Introduction 

-Clinical  Methods  of  the  Examination  of  Blood 
Ev  A.  LAZARUS 


Tlie  quantity  of  blood 

The  number  of  red  bloixl  corpuscles 

Relative  size  of  red  blood  cori^uscles 

Haemoglobin  content  of  the  blood . 

Colour  index 

Specific  gravitj^  of  blooil     . 

Hygrsemometry 

Total  volume  of  red  blood  corpuscles 

Reaction  of  blood   . 

Coagulability  of  blood 

Separation  of  serum 

Resistance  of  red  blood  corpuscles 

Cryoscopy   .... 


2 
5 

12 
13 
17 
19 
22 
22 
24 
26 
27 
28 
29 


CHAPTER  II 

The  Morphology  of  the  Blood 
Bv  A.  LAZARUS 


(A)  Methods  of  Examination 

Making  dry  films     . 

Fixing  dry  films 

Staining  dry  films  . 
Theory  of  staining 
Combination  staining 
Triacid  solution 
Otlier  dj'^e  solutions 
Vital  staining   . 

Recognition  of  glycogen  in  blood 

xi 


30 

30 
33 

36 

39 
40 
41 
43 
44 
51 
52 


Xll 


CONTENTS 


Microscopical  test  for  the  distribution  of  alkali  in  blood 
Bremer's  reaction     ..... 

(B)  NoRMAX  AND  Pathological  Histology  of  the  Blood 

The  red  blood  corpuscles     . 

Structure      .... 

Diminution  of  haemoglobin  content 

Polychromatojihilia 

Punctated  erythrocytes 

Poikilocytes 

Nucleated  red  blood  corpuscles 

Normoblasts  and  niegaloblasts 
Physiological  occurrence 
The  fate  of  the  nucleus  of  the  erythrocytes 
The  clinical  differences  of  erythroblasts 

Bibliography         .... 


PAGE 

53 

54 

56 
56 

57 
58 
58 
61 
67 
68 
69 
71 
72 
74 

79 


CHAPTER  III 

The  White  Blood  Corpuscles 
By  O.  NAEGELI    . 

I,  Normal    Histology    and    Classification    op    the    White 
Blood  Corpuscles 
The  lymphocytes 
The  large  mononuclear  leucocytes 
The  transition  forms    . 

The  polymorpho-nuclear  neutroj^hile  leucocytes 
The  eosinophile  cells    . 
The  mast  cells  .... 
Pathological  forms  of  white  blood  coiyuscles 
The  neutrophile  myelocytes    . 
The  eosinophile  myelocytes 
The  mast  myelocytes    . 
The  myeloblasts 
The  "  stimulation  "  forms 
The  plasma  cells 
Arneth's  method 

II.  On  the  Origin  of  the  White  Blood  Corpuscles 
(a)  The  spleen  .... 

(h)  The  Ij'mphatic  glands    . 
(c)  The  bone  marrow 


.     87 

90 

90 

94 

95 

95 

97 

98 

99 

99 

100 

101 

101 

104 

106 

107 

109 
111 
116 
124 


CONTEN'IS  xiii 


PAO> 
III,    On  THIO  DlCMONHTHATlON  AND  SlONIFKJA.NCK  OF  CkIJ-  OkANULKS      133 

HisLory  of  givuiule  researclies  since  Ehrlicli'H  diwcovery 
Metliods  of  (liMiionstratioii 


Vital  .sUiiiiiiig  of  granules  .... 
Altmann's  Ijioljlast  tlieoiy  .... 
Granules  as  metabolic  products  oi  tlic  cells  (Eiulicli) 
Secretory  phenomena  in  granulated  cells 

IV.  Thk  DuALisTic  Theory    .  ,  .  ,  . 

V.  Leucocytosis  ...... 

The  biological  significance  of  leucocytosis 
The  morj)liology  of  leucocytosis 

(a)  Polyinorpho-nuclear  neutrophil  leucocyto.sis 
Definition  .... 

Clinical  occurrence 

Origin       ..... 

(h)  Polymorpho-nuclear  eosinophil  leucocytosis 
Definition  .... 

Clinical  occurrence 

Origin       ..... 

(c)    Mast  cell  leucocytosis.  .  .      '       . 

VI.  Leuk.«jiia  (Mixed  Leucocytosis) 

Lymphatic  leukaemia  ..... 
Myeloid  leukremia       ..... 

Mori^hological  characters .... 

Origin 


133 

136 
137 
141 
142 
14.5 

146 

151 
1.52 
159 
160 
160 
161 
164 
164 
164 
165 
170 
175 

176 

178 
180 
181 
192 


BiBLIOGRArHY  .  .  .  .  .  .  ,193 


CHAPTER  lY 

The  Blood  Platelets  :  The  H^moconia 

By  A.  LAZARUS  .  .  .202 

Bibliography.  ......    208 


ANEMIA 

CHAPTER   I 

INTRODUCTION 

DEFINITION— CLINICAL  METHODS  OF  EXAMINING 
THE  BLOOD 

The  term  "  aureiiiia "  as  it  is  applied  in  clinical  medicine  does 
not  possess  exactly  the  same  meaning  as  the  limitations  which 
scientific  investigation  has  imposed  upon  it  would  suggest.  In  the 
former  certain  prominent  external  symptoms  are  regarded  as  the 
characteristics  of  anaemic  conditions :  pallor  of  the  skin  and,  as 
compared  with  the  normal  condition,  a  slighter  degree  of  redness 
of  the  mucous  membranes  of  the  eyes,  lips,  oral  cavity,  and  fauces. 
Not  only  is  the  existence  of  an  anaemia  deduced  from  the  presence 
of  these  signs,  but  even  the  degree  of  the  affection  is  measured 
by  the  extent  of  the  symptoms. 

It  is  obvious  that  a  definition  which  is  formulated  on  such  a 
common  and  elementary  symptom  complex  must  include  conditions 
which  do  not  belong  to  it  at  all,  while  other  conditions  may  perhaps 
be  excluded  which  on  account  of  their  nature  should  be  grouped 
with  it.  This  fact  is  responsible  for  a  number  of  uncertainties 
and  contradictions. 

It  is  therefore  the  first  problem  of  a  scientific  consideration  of 
anaemic  conditions  to  carefully  define  their  extent.  The  external 
symptoms  mentioned  above  will  be  found  to  be  little  suitable  for 
such  a  task,  although  it  must  be  admitted  that  when  applied  in 
the  proper  place  they  are  of  practical  importance. 

The  word  anaemia  in  its  etymological  sense  deals  with  a  blood 
the  content  of  which  is  smaller  than  in  health.     This  abnormality 


2  INTRODUCTION 

may  be  general  and  affect  the  whole  organism,  or  it  may  be  local 
and  affect  only  a  limited  area  or  a  single  organ.  The  latter  forms, 
the  local  anae-mias,  do  not  enter  into  the  scope  of  the  present 
work. 

The  blood  content  of  an  organism  can  clearly  differ  from  that 
of  a  healthy  individual  in  two  ways  :  quantitatively  and  qualitat- 
ively. A  diminution  of  the  total  quantity  of  blood,  without  any 
alteration  of  its  composition,  may  be  present;  this  is  called 
oligcemia.  On  the  other  hand,  the  diminution  of  the  quality  of 
the  blood  may  be  absolutely  independent  of  the  total  quantity, 
and  must  be  recognised  primarily  by  the  diminution  of  those  com- 
ponents of  the  blood  which  are  physiologically  most  important. 
Accordingly  the  principal  types  of  qualitative  diminution  of  the 
blood,  which  are  recognised,  are  the  diminution  of  the  haemo- 
globin content  (oligochromcemia),  and  the  diminution  of  the  red 
blood  corpuscles  (oligocythcemia). 

All  conditions  in  which  a  diminution  of  the  haemoglobin 
content  is  ascertainable  must  be  regarded  as  anaemic.  In  the 
majority  of  cases,  even  if  this  is  not  quite  constant,  oligaemia 
and  oligocythsemia  exist  simultaneously  in  varying  degrees. 

The  most  important  methods  of  clinical  haematology  depend 
directly  or  indirectly  on  the  recognition  of  these  changes. 

Up  to  the  present  no  clinically  applicable  method  for  the 
determination  of  the  total  quantity  of  blood  has  been  introduced. 
It  is  possible  to  a  certain  extent  to  utilise  the  observations 
mentioned  above  of  the  symptoms  of  redness  or  pallor  of  the 
skin  and  mucous  membranes  for  this  purpose.  These  symptoms 
are,  however,  dependent  to  a  great  extent  on  the  composition 
of  the  blood,  and  not  solely  on  the  amount  of  blood  contained 
in  the  peripheral  vessels.  In  order,  therefore,  to  utilise  this 
means  as  a  measure  of  the  total  quantity  of  blood,  it  is  advisable 
to  have  regard  to  those  isolated  vessels  which  are  visible  to  the 
naked  eye,  e.g.  in  the  sclera.  The  most  useful  way,  however,  is 
to  observe  the  size  of  the  vessels  in  the  fundus  of  the  eye  by 
means  of  the  ophthalmoscope.  Eaehlmann  has  shown  that  in 
60  per  cent,  of  cases  of  chronic  anaemia,  in  which  the  skin  and 


rNTRODUCTION  3 

mucous  membranes  arc  pule,  hyperfcmia  of  tlio  retina  exists. 
This  proves  that  the  blood  circulating  in  tlie  vesHcls  is  paler 
but  not  sparser  than  normal.  The  character  of  tlie  pulse  also 
may  give  an  ini])()rtaiit  indication  in  cases  in  which  the  (HniiMu- 
tion  of  the  (Quantity  of  blood  is  considerable ;  in  marked  oliga^mia 
a  very  small  and  soft  pulse  is  always  found. 

The  wa,y  hi  which  fresh  wounds  bleed  may  serve  as  a  criterion 
of  the  quantity  of  blood  ;  this,  however,  can  only  be  utilised  within 
certain  limitations,  depending  to  a  large  extent  on  the  coagul- 
ability of  the  blood.  Those  who  have  had  occasion  to  examine 
the  blood  of  anaemic  persons  frequently  will  have  experienced 
that  this  behaviour  is  subject  to  great  variations.  In  certain 
cases  scarcely  a  drop  of  blood  can  be  obtained  in  the  ordinary 
way,  while  in  other  cases  the  blood  flows  freely.  There  is  little 
risk  of  mistake,  if  an  absolute  diminution  of  the  total  quantity 
of  blood  is  assumed  in  the  former  case.  The  degree  of  fulness 
of  the  peripheral  vessels  is,  however,  only  an  index  of  relative 
value,  since  the  blood  content  of  the  internal  organs  may  be 
quite  different. 

The  task  of  determining  the  exact  quantity  of  blood  in  a 
body  in  figures  has  always  been  one  of  utmost  importance.  The 
solution  would  mark  a  very  great  advance  in  hsematology.  Of 
the  methods  which  have  hitherto  been  suggested  for  use  in 
clinical  medicine,  that  emanating  from  Tarchanoff  deserves 
mention.  Tarchanoff  proposed  that  by  determining  the  loss  of 
water  during  profuse  sweating,  and  by  comparative  red  blood  cell 
counts  both  before  and  after  the  sweating,  an  estimate  of  the 
quantity  of  blood  could  be  arrived  at.  This  method,  apart 
from  many  theoretical  difficulties,  is  much  too  complicated  to 
be  applicable  to  practice. 

Quincke  attempted  to  determine  the  quantity  of  blood 
by  means  of  calculations,  while  carrying  out  therapeutic  trans- 
fusion of  blood.  The  quantity  of  blood  in  the  person  into 
whose  vessels  blood  is  being  transfused  can  be  calculated  by 
means  of  a  simple  mathematical  formula,  from  the  number  of 
red  cells  in  his  blood  before  and  after  the  transfusion,  and  from 


4  INTRODUCTION 

the  quantity  of  the  transfused  blood  and  the  number  of  cor- 
puscles contained  therein.  But  even  this  method  is  only 
applicable  in  certain  cases,  and  is  open  to  some  theoretical 
objections.  In  the  first  place,  it  is  dependent  on  the  relative 
content  of  red  corpuscles  of  the  blood,  inasmuch  as  the 
transfusion  of  normal  blood  into  normal  blood  would  not  effect 
any  change  in  the  number.  This  suffices  to  show  that  this 
method  is  only  of  use  in  a  few  special  cases.  It  has  been 
demonstrated  that  an  increase  of  red  corpuscles  in  each  c.mm. 
takes  place  in  an  individual  with  a  very  low  red  blood  cell 
count,  into  whom  normal  blood  has  been  injected,  but  it  is 
extremely  risky  to  attempt  to  determine  the  amount  of  the 
pre-existing  blood  from  this  calculation,  since  there  is  no  doubt 
that  the  act  of  transfusion  directly  produces  compensating 
currents  of  fluid  and  changes  in  the  distribution  of  the  blood. 

The  same  objection  may  be  offered  to  the  suggestions  recently 
made  by  Kottmann  and  Plesch.  These  observers  injected  physio- 
logical saline  solution  intravenously  in  large  quantities,  and  after 
five  minutes  determined  the  total  volume  of  red  blood  corpuscles 
(Kottmann)  or  haemoglobin  (Plesch)  and  compared  the  values 
gained  with  those  derived  from  similar  counts  before  the 
injections.  Apart  from  the  objections  mentioned  above,  there 
are  objections  raised  from  the  medical  point  of  view  against  the 
introduction  of  such  injections  for  the  purpose  of  clinical 
examination.  The  injections  are  often  followed  by  a  considerable 
rise  of  temperature. 

The  method  employed  by  Morawitz  of  determining  the 
quantity  of  blood  in  an  arm  by  means  of  a  plethysmograph  and 
of  calculating  from  this  the  total  quantity  in  the  body  seems  to 
be  quite  worthless,  in  view  of  the  local  and  temporary  variations 
in  the  distribution  of  the  blood,  which  cannot  be  ascertained 
but  which  are  certainly  considerable. 

Haldane  and  Lorrain-Smith  have  attacked  the  problem  from 
another  standpoint  and  have  used  a  comparatively  simple  method, 
which,  however,  is  not  quite  free  from  objection  on  the  point  of 
safety.     They  caused  their  animals  to  breathe  in  a  definite  amount 


INTRODUCTTON  5 

of  CO,  then   ;i,l)slra,c,t(;(l  siiiiill  ([uiiiilili(!K  of  blfjcKl  ii,)i(l  jiHcertained 
without  (h'Cficiilty  tlio  (JO  codIohI.  (if  the  tot;iJ  i|U.'uitity  of  hlood. 

The  resultH  obtained  in  this  way  did  not  a,<r)'ec  with  tlioHo 
which  liad  previously  l)een  acec])ted  in  pliy.siology.  According 
to  lialdane  and  Lorrain-Sniith,  the  relation  between  the  total 
quantity  of  blood  and  the  body  weight  in  man  varies  between 
1  :  IG  and  1  :  30,  while  the  average  stands  at  1 :  20'5,  as  compared 
with  the  hitherto  accepted  average  value  of  1  :  13.  ])ouglas, 
however,  compared  Haldane  and  Lorrain-Smitli's  method  directly 
with  Welcker's  by  animal  experiment,  and  found  that  the  results 
tallied  well. 

Lorrain-Smith  first  applied  this  method  for  clinical  purposes, 
and  showed  that  in  chlorosis  there  is  always  an  increase  in  the 
total  quantity  of  blood.  The  same  author,  working  with  M'Kisack, 
found  the  total  quantity  of  blood  in  a  boy  aged  12  years,  who  was 
suffering  from  adhesive  psricarditis  with  chronic  cyanosis  nearly 
twice  as  great  as  normal.  Further  communications  have  been 
made  by  Parkes  Weber  on  experiments  carried  out  by  Haldane 
and  Boycott  and  himself,  and  also  by  Orum.  These  observations 
showed  that,  in  cases  of  megalosplenic  and  secondary  polycy- 
themia, the  quantity  was  two  and  a  half  to  three  times  that 
of  the  normal  quantity  of  blood. 

There  is  no  character  of  the  blood  that  has  been  so  carefully 
and  frequently  measured  as  the  number  of  red  corpuscles  in  a 
c.mm.  of  blood.  The  comparatively  easy  management  of  the 
counting  apparatus  and  the  guarantee  of  an  apparently  absolute 
measure  have  procured  a  ready  acceptance  of  the  counting 
methods  for  clinical  practice.^  Thoma-Zeiss's  or  similarly 
constructed  apparatus  are  now  in  general  use  for  the  counting 
of  blood  corpuscles.  It  is  presumed  that  the  principles  on  which 
these  apparatus  are  constructed  and  their  methods  of  employ- 
ment are  known.  A  lai'ge  number  of  tluids  may  serve  to 
dilute    the    blood,    all    of    which    are    capable    of    preserving 

'■  For  the  detenniuation  of  the  proportions  of  white  to  red  lilood  corpuscles,  a.s 
well  as  of  the  various  forms  of  leucocytes  to  one  another,  see  the  morphological 
section,  p.  32. 


INTRODUCTION 


the  shape  and  colour  of  the  red  corpuscles,  of  preventing  them 
from  clumping  and  of  permitting  them  to  sediment  rapidly. 
Pacini's  and  Hayem's  fluids  are  the  best  known  of  these : 


Pacini's  Fluid. 


Hydrarg-perchloridi 
Sodii  chloridi 
Glycerin! 
Aquae  dest.  . 


Hayem's  Fluid. 


2-0 

grms. 

4-0 

)3 

26-0 

JJ 

226-0 

5> 

0-5 

grms. 

5-0 

J5 

10 

JJ 

200-0 

J> 

Hydrarg-perchloridi       .         .         . 
Sodii  sulphatis      .         .         .         .         . 

Sodii  chlorat         ...... 

Aquae  dest.   ....... 

The  results  obtained  by  these  methods  of  counting  are 
sufficiently  exact  for  practical  purposes,  since,  according  to  the 
researches  of  E.  Thoma  and  I.  P.  Lyon,  which  have  been  con- 
firmed by  numerous  observers,  the  experimental  error  is  low. 
When  200  cells  are  counted  it  is  5  per  cent.,  when  1250  cells 
are  counted  it  is  2  per  cent.,  with  5000  cells  it  is  1  per  cent., 
and  with  20,000  cells  0-5  per  cent.). 

As  far  as  the  practical  application  of  the  method  is  concerned, 
further  considerations  must  be  taken  into  account  which  exercise 
an  unfavourable  influence  on  the  accuracy  of  the  values. 
Cohnheim  and  Zuntz,  inter  alia,  have  shown  that  the  blood  in 
the  larger  vessels  reveals  a  con^ant  composition,  but  that  in  the 
smaller  vessels  and  capillaries  the  corpuscular  elements  are 
subjected  to  considerable  variations  as  to  number,  even  in  other- 
wise normal  blood.  For  example,  samples  of  capillary  blood 
taken  from  both  sides  of  persons  suffering  from  hemiplegia  do 
not  contain  the  same  number  of  corpuscles;  while  marked 
hypersemia,  cold,  etc.,  increase  the  number  of  red  cells  locally.  It 
is  therefore  necessary  that  blood  taken  for  the  purpose  of 
making  counts  should  be  derived  only  from  those  portions  of 
the  body  which  are  not  subjected  to  marked  variations,  that  all 


IN'nU)I)(JCTI()N  7 

procedures  should  bo  avoided  wliich  could  alter  the  eajjillaiy 
circulation,  such  as  violent  rubbing,  massage,  and  the  like,  and 
that  the  examination  should  be  undertaken  at  a  time  of  day 
when  the  number  of  blood  corpuscles  is  not  artificially  influenced 
by  the  taking  in  of  food  or  by  medicaments. 

It  is  usual  to  take  the  blood  from  the  tip  of  the  finger,  and 
only  when  this  is  rendered  inadvisable,  e.g.  when  there  is 
oedema  of  the  finger,  to  select  other  situations,  such  as  the 
lobule  of  the  ear,  the  great  toe  (especially  in  children),  etc.  It 
is  inexpedient  to  make  a  prick  with  a  sharp  needle  or  with  a 
specially  constructed  open  or  hidden  lancet ;  instead  of  all  the 
complicated  apparatus,  the  best  instrument  for  the  purpose 
is  a  new  steel  nib,  one  point  of  which  is  broken  off,  or  a 
Sonnecken's  vaccination  lancet.  The  nib  or  lancet  can  be 
readily  sterilised  by  heating  in  the  open  flame,  and  by  their 
means  a  more  suitable  cut,  rather  than  a  prick,  is  obtained,  from 
which  the  blood  flows  freely  without  the  aid  of  marked  pressure. 

The  material  from  which  the  countings  of  red  blood 
corpuscles  in  healthy  persons  has  been  determined  and  published 
seems  to  be  too  extensive  to  deal  with.  According  to  the  exact 
compilations  of  Keinert  and  von  Limbeck,  the  following  values 
(calculated  for  cubic  millimetres  and  expressed  in  round  figures) 
may  be  regarded  as  physiological : — 

Males. 


1 

Maximum. 

Minimum. 

Average. 

7,000,000 

4,000,000 

5,000,000 

Females. 

Maximum. 

Minimum. 

AA'erage. 

5,250,000 

4,500,000 

4,500,000 

8  INTRODUCTION 

The  difference  between  the  two  sexes  only  exists  from  the 
time  of  puberty  in  women.  Up  to  the  time  of  the  onset  of  the 
first  menstruation  the  number  of  red  blood  corpuscles  is  even  a 
little  larger  (Stierlin). 

The  only  other  variation  in  the  number  of  red  blood 
corpuscles  due  to  the  age  of  the  individual  is  found  in  the  case 
of  newly  born  infants,  in  whom  polycythsemia  is  always  present 
(up  to  8 1  millions  during  the  first  few  days  of  life,  E.  Schiff). 
From  the  first  taking  in  of  food,  however,  the  number  decreases 
gradually,  albeit  in  stages,  until  the  normal  is  reached,  which 
takes  place  in  about  ten  to  fourteen  days.  The  oligocythgemia, 
which  is  occasionally  observed  during  advanced  age,  is,  according 
to  Schmaltz,  not  a  regular  phenomenon,  and  should  therefore  not 
be  regarded  as  a  physiological  peculiarity  of  senility,  but  must 
be  ascribed  to  the  manifold  active  circumstances  which  affect  this 
age.  , 

The  influence  which  the  intake  of  food  tends  to  exercise  on 
the  number  of  red  blood  corpuscles  must  be  ascribed  in  the  main 
to  the  addition  of  water,  and  is  so  insignificant  that  the  varia- 
tions lie  as  a  rule  within  the  limits  of  error  of  the  method. 

Other  physiological  processes :  menstruation  (i.e.  a  single 
period),  pregnancy,  lactation — do  not  alter  the  number  of  blood 
cells  to  any  appreciable  extent.  Nor  are  there  any  dijfferences 
between  the  numbers  in  arterial  and  venous  blood. 

All  the  fluctuations  in  the  number  of  blood  corpuscles 
which  lie  within  physiological  limits  are  dependent  on 
vasomotor  influences  (according  to  Cohnstein  and  Zuntz). 
Stimuli  which  cause  a  contraction  of  peripheral  vessels  lessen  the 
number  of  red  blood  corpuscles  m  situ;  stimulation  of  vaso- 
dilators, on  the  other  hand,  produces  a  reverse  effect.  This  means 
that  the  physiological  variations  in  the  number  in  any  given  area 
is  only  an  expression  of  an  altered  distribution  of  the  red  elements 
within  the  blood  channels,  and  is  quite  independent  of  new 
formation  and  destruction  of  the  cells. 

Climatic  conditions  appear  to  have  a  great  influence  on  the 
number  of  blood  corpuscles.     This  matter  is  of  equal  importance 


INTRODUCTION  9 

to  ])liy8i()]()<j,y,  paUiology,  iiud  UicraiJOuLics,  and  liuB  been  llie 
subject  of  lively  delxito  since  Viault  called  attention  to  it  by 
his  investigations  on  the  heights  of  the  Oordillei'a.  His  observa- 
tions, as  well  as  those  of  Mercier,  Egger,  Wolll',  Koeppe,  von 
Jaruntowski  and  Schroder,  Miescher,  Klindig,  and  others  have 
shown  that  when  a  healthy  man  with  a  normal  average  count 
of  5,000,000  per  c.mm.  reaches  a  place  situated  consideraldy 
above  the  sea  level,  tlie  number  of  his  red  blood  corpuscles  begins 
to  increase.  After  from  ten  to  fourteen  days,  during  which 
time  the  numl)er  rises  by  stages,  a  new  average  value  is  reached 
and  becomes  constant.  Tlie  height  reached  is  considerably  above 
the  original  value,  and  is  in  proportion  to  the  difference 
between  the  height  above  sea  level  of  the  original  and  the  new 
place  of  abode.  Those  who  are  born  in  high  altitudes  or  who 
live  there  all  their  lives  show  a  considerably  higher  average  of 
the  physiological  number  of  blood  corpuscles  than  persons  living 
in  lower  lying  situations,  and  this  average  is  usually  even  higher 
than  that  of  persons  who  have  become  acclimatised  to  the  par- 
ticular place  or  who  merely  stay  at  high  altitudes. 

The  following  scale  gives  an  idea  of  the  extent  of  tbe 
increase  in  the  number  of  blood  corpuscles  over  and  above  the 
normal  average  (5,000,000)  : — 


Author. 

Place. 

Height  above 
Sea  Level. 

Increase  of 

V.  JaruntoAVski 
Wolff  &  Koeppe 
Egger 
Viault 

Gorbersdorf 
Eeiboldsgriiu 
Arosa 
Cordillera 

1,840  ft. 

2,296  „ 

6,904  „ 

14,406  „ 

800,000 
1,000,000 
2,000,000 
3,000,000 

Exactly  the  opposite  is  observed  when  a  person  acclimatised 
to  a  high  altitude,  who  shows  these  high  blood  corpuscle  values, 
moves  to  a  place  situated  at  a  lower  level.  Under  these  con- 
ditions the  corresponding  lower  physiological  average  is 
gradually  assumed. 


10  INTRODUCTION 

These  results  have  been  confirmed  in  an  enormously  large 
number  of  observations  of  single  cases.  Some  authors,  however 
(GottstQin,  Meissen,  and  others),  have  expressed  the  opinion 
that  no  material  significance  can  be  attached  to  them,  on  the 
ground  that  these  counts  depend  on  an  illusion;  since  the 
capacity  of  the  Thoma-Zeiss's  cell  is  influenced  by  the  altera- 
tion of  the  external  atmospheric  pressure.  This  objection 
has  been  finally  disproved  by  Schaumann  and  Eosenqvist, 
and  the  values  which  have  been  recorded  are  now  generally 
accepted  as  being  the  accurate  expressions  of  the  numbers  of 
red  blood  corpuscles  per  c.mm. 

At  the  same  time,  it  must  be  pointed  out  that  among  those 
who  really  recognise  the  alteration  in  the  number  of  red  blood 
corpuscles  a  difference  of  opinion  exists  or  existed  as  to  the 
significance  of  these  processes.  Some  observers  were  inclined  to 
regard  the  variations  in  the  number  of  blood  cells  as  being  wholly 
due  to  the  action  of  vasomotor  processes  similar  to  those  of  which 
mention  has  been  made  above.  In  their  opinion  exposure  to  the 
sun's  rays,  differences  of  temperature,  and  the  like  are  the  most 
important  factors.  A.  Loewy  and  his  colleagues  have  shown  that 
the  number  of  blood  corpuscles  in  the  capillaries  may  vary  in 
either  direction  to  the  extent  of  millions  withjn  the  space  of  a 
few  minutes  under  influences  of  this  kind.  Grawitz  has  expressed 
the  opinion  that  the  increase  in  the  number  of  blood  cor- 
puscles is  wholly  explainable  on  the  assumption  of  a  marked 
concentration  of  the  blood,  resulting  from  an  increased  loss  of 
water  by  evaporation  from  the  body  when  existing  at  these 
heights.  He  was  able  to  demonstrate  that  animals  which  were 
kept  in  correspondingly  rarefied  atmospheres  behaved  similarly, 
von  Limbeck,  Schumburg,  and  Zuntz  opposed  this  argument 
with  the  objection,  that  if  the  loss  of  water  could  produce 
such  a  considerable  raising  in  the  number  of  cells  a  corres- 
ponding loss  of  weight  must  also  occur,  and  this  is  not  the 
case. 

Schaumann  and  Eosenqvist  have  recently  contended  that  the 
recorded  increase  in  the  red  blood  corpuscles  at  high  altitudes  is 


INTllODUCTrON  11 

the  result  of  an  actual  new  formation  of  thoHo  colls,  and  that  a 
diminution  in  the  number,  occurring  when  the  subject  returns 
to  lower  levels,  is  caused  by  a  destruction  of  the  red  elements  of 
the  blood.  This  contention  can  be  supported  by  a  large  number 
of  convincing  facts. 

In  the  first  place,  when  a  person  moves  to  a  high  altitude 
the  increase  in  the  red  blood  cells  does  not  take  place  at  once, 
but  frequently  requires  several  weeks  to  develop.  In  the  next 
place,  the  haemoglobin  value,  the  specific  gravity,  and  the  dry 
substance  value  of  the  blood  alters  simultaneously  and  in  the 
same  direction,  although  the  changes  are  not  always  exactly 
proportional.  Thirdly,  as  Koeppe  first  demonstrated,  morpho- 
logical changes  occur  in  the  blood  .cells.  This  observer  noted 
that  as  a  rule  poikilocytosis  and  formation  of  microcytes  took 
place  immediately  the  subject  arrived  at  the  higher  altitude. 
These  changes  are  regarded  as  indications  of  the  endeavour  on 
the  part  of  the  organism  to  raise  the  respiratory  surface  of  the 
total  reservoir  of  hasmoglobin.  Schaumann  and  Eosenqvist,  A. 
Loewy  and  Franz  Mliller  and  also  Fo^,  made  the  observation  that 
when  animals  are  placed  under  corresponding  conditions  a  dis- 
tinct increase  of  the  blood-forming  function  of  the  bone  marrow 
could  be  demonstrated  histologically.  The  most  convincing  proof, 
however,  was  supplied  by  Jaquet  and  Suter,  Abderhalden,  and 
Loewy  and  Miiller,  in  their  experiments,  which  showed  that 
rabbits  and  dogs  which  were  kept  for  considerable  periods  at  a 
height  of  3000  or  6300  feet  above  the  sea  level,  actually  had  a 
larger  total  quantity  of  haemoglobin  than  the  control  animals 
which  were  kept  at  a  lower  level. 

These  facts  justify  the  simple  deduction,  that  under  the 
influence  of  high  altitudes  a  new  formation  of  blood  corpuscles 
and  haemoglobin  actually  takes  place.  Schaumann  and  EosenqAnst 
and  Sellier,  however,  experimented  further  to  determine  which 
were  the  factors  in  connection  with  high  altitudes  which  lead 
to  the  increase  of  the  ha^matopoiesis,  and  concurrently  arrived  at 
the  conclusion  that  diminution  of  the  atmospheric  pressure  is  the 
most  important   factor.     The  crucial  experiment  was  performed 


12  INTRODUCTION 

by  A.  von  Koraiiyi  and  Bence,  by  which  it  was  proved  that  the 
inhalation  of  oxygen  inhibits  the  increase  of  the  elementary 
constituents  of  the  blood,  and  may  even  cause  this  change,  after 
it  has  set  in,  to  disappear. 

The  enormous  amount  of  data  dealing  with  this  point  justified 
an  acceptation  of  the  doctrine  that  life  at  high  altitudes  actually 
calls  forth  an  increased  production  of  blood,  while  the  descent 
from  a  height  to  lower  lying  districts  causes  a  destruction  of  the 
blood  cells.  On  the  other  hand,  it  is  much  more  difficult  to  decide 
(if  this  indeed  be  possible)  what  proportion  of  the  changes  which 
have  been  observed  is  dependent  on  vasomotor  influences,  and 
what  proportion  must  be  ascribed  to  true  hsemopoietic  processes. 
All  that  can  be  said  at  present  is  that  the  vasomotor  influences 
are  undoubtedly  extremely  active,  and  that  both  factors  act 
simultaneously. 

The  influence  of  the  tropics  on  the  composition  of  the 
blood,  and  especially  on  the  number  of  blood  corpuscles,  has 
been  studied,  as  well  as  the  influence  of  high  altitudes.  Both 
Eykmann  and  Glogner  found  that  in  spite  of  the  fact  that 
the  pale  appearance  of  Europeans  in  the  tropics  suggests  some 
blood  change,  no  such  change  can  be  detected.  It  appears 
in  this  connection  also,  that  an  alteration  of  the  distribution  of 
the  blood  without  any  quantitative  changes  is  responsible  for  the 
pallor. 

Thoma-Zeiss's  and  similar  methods  of  counting  blood  corpuscles 
do  not  yield  the  same  marked  reliability  with  ana:;mic  blood  as 
they  do  with  normal  blood,  in  which  the  red  corpuscles  are  all  of 
the  same  size  and  all  contain  the  same  quantity  of  haemoglobin. 
In  anaemic  blood,  as  will  be  shown  later,  the  red  corpuscles  reveal 
considerable  variations.  Some  of  the  cells  are  poor  in  haemoglobin, 
while  others  are  so  small  that  they  cannot  even  be  seen  when 
examined  by  the  moist  methods. 

Slight  differences  in  the  individual  blood  discs  are  seen  in  the 
blood  of  healthy  subjects  when  the  examination  is  carried  out 
in  this  manner.  The  physiological  average  of  the  diameter  of 
the  largest  surface  in  men  and  women  is  8'5,a  (maximum  9'0//, 


INTllODITCTION  13 

and  minimum  0"5///;  Laache,  ITayem,  Scfi.'uiman,  and  oUioi'sj.  Tlio 
differences  bciwcen  the  variouK  clcunonls  bocoiuo  CDiisidei-ably  moro 
marked  in  anuimic  blood.  'J'bo  average  vabies  mu.st  tberefore  be 
arrived  at  l)y  noting  the  mo;i,siirom(!nts  of  a  l;u'g(!  niimljor  of  cells 
taken  at  random,  and  dctoiiiiiiiing  from  siicb  obH('i-v;i,tion«  tlie 
maxima  and  niinimii,.  Wb(3ii  Llio  Vii,riii,tii)ns  in  the  .size  of  Llic 
discs  are  very  great,  ndcrosco])ical  measiircrnents  ;i,re  of  no 
scientific  value. 

Valuable  as  the  knowledge  of  the  absolute  number  of  red 
blood  corpuscles  may  be  in  forming  an  opinion  with  regard  to 
the  course  of  the  disease,  this  knowledge  does  not  throw  any 
light  on  the  hemoglobin  content  of  the  blood,  which  is  the  real 
indicator  of  anaemia.  A  number  of  clinical  methods  serves  the 
purpose  of  determining  this  value.  These  methods  are  either 
direct,  as  the  colorimetric  estimation  of  the  hemoglobin  content ; 
or  indirect,  as  the  determination  of  the  specific  weight,  the 
volume  of  the  red  blood  corpuscles,  and  even  the  determination 
of  the  dry  substance  contained  in  the  total  quantity  of  blood. 

In  dealing  with  the  direct  methods  of  estimating  the 
hemoglobin,  which  aim  at  measuring  the  intensity  of  the 
colour  of  the  blood,  and  accept  this  as  the  index  of  the  pigment 
content,  mention  must  be  made  of  a  simple  one.  This  method 
does  not  yield  results  of  great  accuracy,  but  is  frequently  found 
to  be  of  value  in  permitting  a  rapid,  rough  idea  of  the  state  of 
affairs  to  be  found  at  the  bedside.  The  difference  of  colour 
between  normal  and  anemic  blood  can  be  more  readily  recog- 
nised when  a  drop  of  blood  is  allowed  to  fall  on  a  piece  of 
linen  or  filter  paper,  and  to  spread  spontaneously,  than  when  the 
drop  is  regarded  as  it  issues  from  the  prick  in  the  finger.  A 
little  practice  enables  the  physician  to  ascertain  the  degree  of 
anemia  in  this  manner.  If  this  simple  and  easily  applied 
method  were  more  used  there  is  little  doubt  that  the  habit  of 
resorting  to  the  convenient  diagnosis  of  anemia  in  a  number  of 
doubtful  cases  would  soon  disappear.  This  method  is  further 
usually  sufficient  to  convince  neurasthenic  patients,  who  believe 
that  they  are  anemic,  and  who  look  pale,  that  they  are  mistaken. 


14  INTRODUCTION 

Tallqvist  has  constructed  his  "  hsemoglobin  scale  "  on  this  principle. 
By  its  means  the  haemoglobin  values  may  be  roughly  estimated 
in  stages  showing  10,  20,  30  per  cent,  and  so  on  of  haemoglobin. 

The  most  accurate  apparatus  for  the  measurem-snt  of  the 
colour  intensity  of  the  blood  is  the  Hoppe-Seyler's  colorimetric 
double  pipette.^  This  instrument  contains  an  exactly  titrated 
solution  of  carbon  monoxide  haemoglobin,  which  has  to  be 
matched.  The  reliable  preparation  and  conservation  of  this 
standard  solution  is,  however,  a  matter  of  considerable  difficulty, 
and  for  this  reason  the  method  cannot  be  included  among  those 
which  can  be  applied  clinically.  It  need  not  be  considered  in 
detail  in  this  work.  Zangemeister,  a  pupil  of  Kiihne,  has  described 
an  apparatus  for  colorimetric  estimation,  with  which  he  has  carried 
out  a  number  of  haemoglobin  determinations.  The  apparatus  de- 
pends on  the  principle  that  the  pigment  content  may  be  calculated 
from  the  measurement  of  the  column  of  fluid,  which  has  been 
matched  as  far  as  colour  is  concerned  to  a  standard  solution. 
Zangemeister  employed  a  methaemoglobin  glycerine  solution 
derived  from  pig's  blood  as  his  standard  solution.  As  far  as  the 
author  is  aware  the  clinical  value  of  this  method  has  not  yet 
been  tested.  It  is,  however,  highly  desirable  that  this  testing 
should  be  undertaken.  The  chromophotometer,  which  was  de- 
scribed by  Plesch  and  employed  in  physiology,  is  much  too  com- 
plicated for  practical  application. 

The  physician  must  therefore  be  satisfied  for  the  present  to 
work  with  less  exact  apparatus,  in  which  tinted  glass  or  more 
or  less  stable  pigment  solutions  are  employed  for  the  purpose 
of  having  a  coloured  solution  to  which  the  colour  of  the  blood 
is  to  be  matched.  Fleischl's  hasmometer  may  be  mentioned  as 
one  which  depends  on  this  principle,  and  Gower's  haemoglobino- 
meter  is  also  freely  used  in  practice,  being  cheaper  than  others 

1  Translator's  Note. — In  this  country  Gower's  hsemoglobinometer,  with  Haldane's 
carbon  monoxide  blood  solution,  is  Avidely  used,  and  yields  results  which  are  as 
exact  as  those  obtained  with  Hoppe-Seyler's  apparatus.  The  standard  tube  is 
sealed  and  retains  its  colour  well,  and  is  quite  uniform.  Each  fresh  tube  bought, 
however,  should  be  re-standardised  by  the  clinician  against  a  normal  sample  of 
blood,  containing  five  million  erythrocytes. 


INTRODUCTION  15 

and  yielding  just  as  good  results.  Miescher's  modification  of 
Fleischl's  hsemometer,  apart  from  being  more  accurate,  possesseH 
an  advantage  over  the  original  apparatus  in  that  it  records  the 
absolute  as  well  as  the  percentage  values  of  iia^moglobin  in  the 
blood. 

Sahli's  hffimometer  has  acquired  clinical  popularity  for  good 
reasons.  This  instrument  is  provided  with  a  test  colour  in  the 
form  of  a  permanent  diluted  solution  of  ha;matin  chloride.  The 
blood  sample  must  therefore  be  taken  in  one-tenth  normal 
hydrochloric  acid,  in  order  that  the  haemoglobin  may  be  con- 
verted into  ha;matin  chloride.  It  is  unnecessary  to  enter  into 
a  detailed  description  of  the  method  of  using  this  apparatus, 
since  each  instrument  is  provided  with  minute  details  of  the 
mode  of  use.  The  same  also  applies  to  the  various  apparatus 
mentioned  above.  Suffice  it  to  mention  that  each  Sahli's 
apparatus  is  now  adjusted  to  a  standard  sample  of  healthy 
human  blood  containing  5,000,000  red  blood  corpuscles. 

All  these  apparatus  indicate  what  percentage  of  the  normal 
quantity  of  haemoglobin  the  sample  of  blood  under  examination 
possesses,  and  yield  results  which  for  practical  purposes  and  as 
relative  values  are  sufficiently  accurate.  In  the  hands  of  inex- 
perienced observers,  however,  errors  of  10  per  cent,  and  more 
may  occur  (see  K.  H.  Meyer). 

Biernacki  has  raised  objections  to  the  colorimetric  methods 
of  estimating  the  haemoglobin  content  quantitatively,  on  the 
ground  that  the  colour  intensity  of  blood  is  not  wholly 
dependent  on  its  haemoglobin  content,  but  is  partly  due  to  the 
coloration  of  the  plasma  and  to  the  quantity  of  albumin  con- 
tained in  the  blood.  This  objection,  however,  cannot  be  sup- 
ported with  regard  to  the  estimation  of  the  colour  value  by 
means  of  the  apparatus  mentioned,  since  the  blood  is  diluted 
so  considerably  with  water  that  any  differences  wliich  may 
have  originally  been  present  become  negligible. 

Of  the  methods  of  determining  the  hemoglobin  content  of 
blood  indirectly,  the  one  by  means  of  which  the  pigment  is 
calculated  from  the   iron   content  of  the  blood  would  seem  to 


16  INTRODUCTION 

be  quite  accurate,  since  hsemoglobin  possesses  a  constant  Fe 
content  of  0*42  per  cent.  The  correctness  of  this  may  be 
admitted  as  far  as  normal  blood  is  concerned ;  a  definite  pro- 
portion between  licemoglobin  and  iron  content  of  the  blood 
actually  exists. 

This  method,  however,  is  not  to  be  recommended  for  deter- 
mining the  haemoglobin  in  pathological  blood.  If  the  blood  of 
an  ansemic  person  be  tested  under  the  microscope  with  chemicals 
which  give  a  reaction  with  iron,  it  will  be  found  that  many  red 
blood ,  corpuscles  give  the  iron  reaction.  This  would  mean  that 
iron  has  been  detected  which  is  not  in  the  form  of  haemoglobin. 
Iron  may  be  present  in  the  form  of  the  albuminate  of  iron,  which 
is  not  recognisable  as  such  in  the  morphotic  elements  including 
the  white  corpuscles.  Further,  it  is  known  that  the  iron  content  of 
all  the  organs  of  ansemic  persons  is  markedly  increased  (Quincke), 
obviously  as  a  result  of  the  increased  destruction  of  haemoglobin 
("  sediment "  iron,  '•  spodogenous  "  iron).  In  the  number  of  in- 
stances, consideration  must  be  given  to  the  fact  that  the  thera- 
peutic application  of  iron  will  increase  the  quantity  of  this 
metal  in  the  blood  and  tissues.^  The  foregoing  will  show  that 
any  attempt  to  calculate  the  hsemoglobin  content  from  the 
iron  content  in  pathological  conditions  is  unreliable. 

This  discursion  was  considered  to  be  necessary  on  account  of 
Biernacki's  work,  inasmuch  as  the  procedure  of  deducing  from 
the  iron  content  the  hsemoglobin  content  of  the  blood  has  led 
to  many  curious  results.  For  example,  in  two  cases  of  mild 
and   one   of  severe   chlorosis  he  found   the   iron   content   quite 

^  Translator's  Note.- — It  is  extremely  doubtful  whether  this  argument  can  be 
regarded  as  good.  Expei'imental  evidence  exists  that  iron  given  by  the  mouth 
is  not  utilised  by  the  organism  to  build  up  haemoglobin  ;  and  further,  that  very 
little  if  any  iron  in  inorganic  combination  is  absorbed  from  the  intestine.  More 
than  this,  the  translator  was  able  to  show  that  iron,  existing  in  the  form  of  free 
cations,  exerts  a  highly  toxic  action  on  the  tissues,  and  causes  death  in  doses  of 
a  few  milligrammes  per  kilo  body  weight.  Considering  the  number  of  grammes  of 
iron  taken  as  medicine,  it  must  be  assumed  that  whatever  small  proportion  is 
absorbed  it  is  rapidly  converted  into  complex  iron  combinations,  and  cannot 
accumulate  in  reasonable  quantities  in  the  blood. 


IN1JU)DTJCTI()N  17 

normal.  From  this  ho  argiuid  thai  in  chloroHis  and  other 
forms  of  anaemia  there  is  no  diminution,  but  rather  a  relative 
increase  of  haemoglobin,  and  that  the  otlier  albuminous 
components  of  the  blood  are  diminished.  Even  if  these  iron 
determinations  could  be  shown  to  be  free  from  error  (and  it 
must  be  pointed  out  that  tliey  have  been  directly  contravened 
by  other  authors),  what  has  been  said  above  will  suffice  to  yrove 
that  the  far-reaching  deductions  which  Biernacki  has  drawn 
from  his  results  are  untenable.  It  must  further  be  pointed  out 
that  delicate  analyses  like  those  on  which  Biernacki  based  his 
conclusions  could  only  be  accepted  if  confirmed  by  control 
experiments. 

The  number  of  erythrocytes  ^  and  the  heemoglobin  value 
stand  in  close  relationship  to  one  another,  but  there  is  no 
complete  parallelism  between  them.  In  certain  pathological 
conditions  the  haemoglobin  content  is  higher  than  the  number 
of  red  blood  corpuscles  would  suggest,  while  in  others  it  is 
lower.  In  some  cases  the  diminution  of  the  number  of 
erythrocytes  corresponds  exactly  to  the  diminution  of  the 
haemoglobin  value.  For  example,  in  a  man  a  red  cell  count  of 
four  millions  would  correspond  to  a  haemoglobin  value  of  80. 
But  in  chlorosis,  inter  alia,  the  diminution  of  the  htemoglobin 
is  greater  proportionately  than  the  diminution  of  the  red  cells, 
so  that  a  reduction  to  80  per  cent,  of  red  cells  might  exist 
simultaneously  with  a  reduction  to  60  per  cent,  of  haemoglobin. 
If  the  haemoglobin  percentage  be  divided  by  the  red  cell  per- 
centage, the  quotient  may  be  regarded  as  the  expression  of 
this  relation.  This  quotient  is  called  the  "  blood  corpuscle 
value "  or  the  "  colour  index."     In   the  instance  cited  above  it 

would  be —-  =  0"75.     The  colour  index  maybe  even  neater  than 
80  Jo 

1,  when  the  diminution  of  the  haemoglobin  is  smaller  than  that 
of  the  erythrocytes.  This  occurrence  was  first  observed  in  pro- 
gressive pernicious  anaemia.     According  to  Meyer  and  Hieneke, 

^  N.B. — The  term  "erythrocyte"  is  not  usually  employed  by  English  writers, 
but  it  is  so  handy  that  use  will  be  made  of  it  in  this  work. 
2 


18  INTRODUCTION 

the  colour  index  of  the  foetal  blood  is  normally  greater  than 
1,  e.g.  in  the  fifth  month  it  is  1-6  and  in  the  seventh  month 
it  is  1-4. 

The  disturbance  of  the  parallelism  between  the  number  of 
blood  corpuscles  and  the  hsemoglobin  content  is  dependent  both 
on  the  changes  in  size  of  the  red  blood  cells  and  on  the  fact 
that  the  individual  blood  discs  may  be  either  poor  in  haemoglobin 
or  anaemic,  or  under  certain  conditions  they  may  be  rich  in  haemo- 
globin and  appear  as  cells  of  an  embryonal  type  in  the  blood 

It  thus  becomes  clear  that  it  is  not  permissible  to  regard 
the  number  of  erythrocytes  in  a  given  sample  of  blood  as  an 
independent  indicator.  It  can  only  be  of  importance  when 
considered  in  its  relations  to  the  result  of  the  determination  of 
the  hsemoglobin  and  of  the  histological  examination.  In  con- 
nection with  this  matter,  it  is  necessary  to  call  attention  to 
the  fact  that  a  not  inconsiderable  source  of  error  in  the 
counting  of  erythrocytes  in  pathological  cases  depends  on  the 
failure  of  the  observer  to  recognise  and  count  the  smallest 
forms  of  cells,  when  using  the  objectives  which  are  usually 
employed  for  the  purpose. 

For  this  reason  it  is  at  times  desirable  to  supplement  the 
record  of  the  number  of  red  blood  corpuscles  by  a  determina- 
tion of  the  size  of  the  individual  cells.  This  is  carried  out 
directly  by  measuring  the  diameter  by  means  of  an  ocular- 
micrometer,  which  may  be  applied  both  with  dried  and  with 
moist  preparations,  although  the  former  are  preferable  on 
account  of  simplicity.  The  carrying  out  of  this  method, 
however,  necessitates  special  care  with  regard  to  technique. 
It  will  be  noticed  that  the  red  blood  corpuscles  in  normal 
blood  when  lying  in  a  thick  layer  appear  smaller  than  when 
lying  in  a  thin  layer  in  a  dry  preparation.  This  difference  is 
due  to  the  fact  that  in  the  thick  layer  the  red  discs  float 
about  in  the  serum  before  drying,  while  in  the  thin  layer 
they  are  connected  to  the  surface  of  the  slide  by  means  of  a 
capillary  layer  of  serum.  The  drying  takes  place  almost  in- 
stantaneously in  the  latter  case,  the  process  starting  from  the 


INTRODUCTION  19 

periphery  of  the  disc,  so  ihut  a  chan;i,c  iji  the  shape  or  size 
of  tlio  cell  cannot  occur.  The  process  of  drying  in  thick  layers 
takes  place  more  slowly,  and  is  therefore  accompanied  by  a 
shrinking  of  the  discs  (see  p.  1  '1  for  figures). 

The  examination  of  the  specific  gravity  of  blood  lias  filways 
been  regarded  as  highly  important,  since  the  number  of 
corpuscles  and  tlie  haimoglobin  content  can  be  calculated  from 
the  measure  of  the  density  of  the  blood.  There  are  two 
methods  which  do  not  necessitate  elaborate  apparatus  and  which 
are  not  too  complicated  for  practical  clinical  purposes  for 
the  carrying  out  of  these  estimations,  and  fairly  extensive  data 
have  been  collected  by  both.  The  one  has  been  devised  by  E. 
Schmaltz,  and  consists  in  weighing  exactly  small  quantities 
of  blood  contained  in  glass  capillaries  (capillary-pycnometric 
method),  while  the  other  was  worked  out  by  A.  Haramerschlag, 
based  on  the  principle  described  by  Fano,  and  consists  in  find- 
ing out  the  proportions  of  a  mixture  of  chloroform  and  benzole, 
in  which  a  drop  of  the  blood  to  be  examined  neither  floats  nor  sinks, 
i.e.  which  possesses  exactly  the  same  specific  gravity  as  the  blood. 

According  to  the  investigations  of  these  authors  and  of  a 
number  of  others  who  have  used  their  methods,  the  specific 
gravity  of  the  blood  as  a  whole  under  physiological  conditions  is 
from  1058  to  1062,  or  on  the  average  1059  (in  women  1056). 
The  specific  gravity  of  the  serum  is  1029  to  1032,  or  on  the 
average  1030.  From  these  figures  it  becomes  clear  that  the 
material  weight  of  the  blood  must  be  largely  caused  by  the  red 
blood  corpuscles.  If  the  erythrocytes  are  reduced  in  number,  or 
if,  while  their  number  remains  at  the  normal  level,  they  become 
less  in  volume,  or  lose  part  of  their  htemoglobin,  the  specific 
gravity  will  be  found  to  be  correspondingly  reduced.  In  all 
anremic  conditions  a  diminution  of  the  specific  gravity  of  the 
blood  must  therefore  be  expected.  And  conversely,  an  increase 
in  the  number  of  red  cells  and  a  rising  of  the  haemoglobin  value 
will  be  associated  with  an  increase  of  the  density  of  the  blood. 

Schmaltz  was  the  first  to  show  that  the  correspondence 
between  the  specific  gravity  and  the  haemoglobin  content  of  the 


20 


INTRODUCTION 


blood  was  much  closer  than  that  between  the  specific  gravity 
and  the  number  of  red  blood  corpuscles.  This  correspondence 
is  so  constant  that  Hammerschlag  expressed  it  in  the  following 
tabular  form — 


Specific  Gravity. 

Haemoglobin  Content  (Fleischl) 

1033-1035      ....         25-30  per  cent. 

1035-1038 

30-35 

1038-1040 

35-40 

1040-1045 

40-45 

1045-1048 

45-55 

1048-1050 

55-65        „ 

1050-1053      . 

65-70 

1053-1055 

70-75 

1055-1057 

75-85 

1057-1060 

85-95 

Dieballa,  who  has  also  studied  this  question  closely,  was  able 
in  part  to  confirm  Hammerschlag's  results,  and  in  part  to  supple- 
ment them.  He  deduced  from  his  comparative  estimations  an 
average  value :  differences  of  10  per  cent,  in  the  haemoglobin 
value  (Fleischl)  correspond  to  rough  differences  of  4'46  per  mille 
in  the  specific  gravity  (measured  by  Hammerschlag's  method).  It 
was  shown,  however,  that  variations  in  the  specific  gravity  up  to 
13 '5  per  mille  are  met  with  without  any  alteration  in  the  haemo- 
globin content,  and  it  was  found  that  these  variations  were 
greater  in  cases  in  which  the  hsemoglobin  value  was  high. 
There  are  regular  differences  between  the  blood  of  men  and  that 
of  women;  in  the  latter  the  specific  gravity  is  from  2  to  2'5  per 
mille  lower  with  the  same  hsemoglobin  value.  When  the 
parallelism  between  the  number  of  erythrocytes  and  the  hsemo- 
globin content  is  markedly  disturbed  the  influence  of  the  stroma 
of  the  red  corpuscles  on  the  specific  gravity  of  the  blood 
becomes  recognisable.  Dieballa  calculated  that  the  stroma  may 
cause  a  difference  of  from  4  to  5  per  mille  in  the  specific 
gravity  of  two  samples  of  blood  having  the  same  hsemoglobin 
values. 


introdtjctto:n  21 

In  tliiH  way  it  will  bo  seen  tluil  tho  df,l,oriiiiiiaiion  oi"  the 
specific  gravity  may  suffice  in  many  cases  for  llio  purpose  of 
determining  tho  relative  htnmoglobin  content  in  a  sam])le  of 
blood.  In  nephritis  and  di,stini)ances  of  the  circulatory  organs, 
and  in  leukaemia,  however,  the  correspondence  between  the  specific 
gravity  and  the  luemoglobin  content  are  masked  by  extraneous 
conditions. 

The  physiological  variations  in  the  specific  gravity  of  the 
blood  of  one  and  the  same  individual,  which  are  due  to  the 
intake  of  fluid  and  the  excretion  of  the  same,  does  not  exceed 
0*003  (Schmaltz).  These  variations  must  correspond  to  those 
which  affect  the  haemoglobin  content  and  the  number  of  blood 
corpuscles,  and  must  occur  under  conditions  similar  to  those 
which  produce  the  last-named  variations. 

A  number  of  investigations,  including  more  particularly  those 
of  Hammerschlag,  von  Jaksch,  von  Limbeck,  Biernacki,  Dunin, 
E.  Grawitz,  and  A.  Loewy  have  avoided  an  omission  of  which  the 
earlier  workers  were  guilty,  by  determining  the  specific  gravity 
of  at  least  one  of  the  constituents  (the  blood  corpuscles  or  the 
serum)  as  well  as  that  of  the  blood  as  a  whole.  These  obser- 
vations all  showed  that  the  red  corpuscles  were  responsible  for 
the  variations  of  the  specific  gravity  of  the  whole  blood.  The 
changes  in  the  cells  were  in  part  variations  in  their  number  ex- 
changes in  their  distribution,  and  in  part  due  to  their  chemical 
lability :  loss  or  gain  in  the  water  content,  variations  in  respect 
to  the  albumin  content,  etc.  The  fluid  of  the  blood  possesses 
much  greater  constancy.  No  material  difference  appears  to 
exist  between  the  serum  and  the  plasma  (Hammerschlag). 
Even  in  severe  pathological  conditions,  in  which  the  blood 
as  a  whole  is  found  to  be  specifically  much  lighter  than 
normal,  the  serum  retains  its  physiological  composition,  or  only 
shows  slight  variations  in  concentration.  Marked  lowering  of 
the  specific  gravity  of  the  serum  is  far  less  often  observed 
in  actual  diseases  of  the  blood  than  in  chronic  renal  diseases 
and  disturbances  of  the  circulation.  E.  Grawitz,  however,  has 
stated  that   certain  anaemias,  especially  those  following  hsemor- 


22  INTRODUCTION 

rhage  and  those  following  wasting  conditions  produce  a  recog- 
nisable .depression  in  the  specific  gravity  of  the  serum.  Even 
if  these  contentions  appear  to  be  somewhat  contradictory,  it 
follows  as  a  result  of  these  observations  that  it  is  necessary  in 
carrying  out  a  scientific  examination  of  the  blood  to  examine  the 
specific  gravity  of  the  serum  or  of  the  corpuscles  in  all  cases, 
as  well  as  that  of  the  blood  as  a  whole. 

A  method  which  is  closely  related  to  the  determination  of  the 
specific  gravity  of  the  blood  is  that  which  aims  at  the  deter- 
mination of  the  dry  substance  of  the  blood,  called  hygraemometry, 
and  which  has  been  introduced  into  clinical  use  by  Stintzing  and 
Gumprecht.  This  examination  is  capable  of  supplementing  the 
methods  already  described  in  a  useful  manner,  since  it  can  be 
carried  out  in  practice  with  small  quantities  of  blood,  which 
can  be  obtained  at  all  times  and  under  all  conditions.  Small 
quantities  of  blood  are  collected  in  minute  weighing  bottles, 
weighed,  dried  for  twenty-four  hours  at  65°  to  70°  C,  and 
then  weighed  again.  It  appears  that  the  values  obtained 
from  these  weighings  of  the  dry  substance  possess  certain 
peculiar  importance,  since  they  do  not  always  give  results 
which  stand  parallel  to  the  specific  gravity,  the  haemoglobin 
content,  or  the  number  of  blood  corpuscles.  The  normal  value 
for  men  is  21-6  per  cent,  and  for  women  19*8  per  cent. 

A  further  procedure  which  admits  of  indirect  deduction  with 
regard  to  the  haemoglobin  values  of  blood  is  the  estimation  of 
the  volume  percentage  of  the  red  blood  corpuscles  in  the  total 
volume  of  blood.  In  order  to  carry  out  this  estimation  it  is 
necessary  to  have  a  method  of  separating  the  corpuscles  from 
the  fluid  of  the  blood,  without  materially  altering  the  composi- 
tion of  the  blood.  The  older  methods  do  not  fulfil  these 
conditions,  for  they  either  depend  on  defibrination  of  the  blood, 
a  process  which  is  not  possible  even  with  the  quantity  of 
blood  available  in  the  clinic,  or  on  the  addition  of  sodium 
oxalate  or  other  substance  which  inhibits  the  coagulation  of  the 
blood.  The  separation  of  the  two  components  of  the  blood  was 
achieved  either  by  simple  sedimentation  or  by  centrifugation  by 


INTRODUCTION  23 

means   of  a   Hpocial  coiitrifuge,  constnicled    hy   P.lix-Ifcfliii  and 
Gartner,  called  ilu^  liicmatocrit. 

Even  tlio  inanirold  diluLion  lluidK  which  arc  used  for  these 
methods  ol'  exaniiuiitioii,  such  as  ])hyKiolofri(;fil  saline  fhiid,  2-5 
per  cent,  solution  ol'  potiissium  hi(;hroiii;i,te,  etc.,  cannot  be 
regarded  as  being  indifierent  as  far  as  the  volume  of  the  red 
corpuscles  is  concerned  (H.  Koeppe).  A  solution  which  does 
not  alter  the  cells  at  all  would  have  to  be  specially  adapted 
to  each  sample  of  blood.  For  this  reason  the  method  suggested 
by  M.  Herz  deserves  consideration,  in  which  the  coagulation 
of  the  blood  in  the  pipette  is  prevented  by  rendering  the 
walls  absolutely  smooth  Ijy  means  of  cod  liver  oil.  Koeppe  has 
modified  this  method  slightly.  He  uses  a  suitably  constructed 
pipette,^  and  after  cleaning  it  carefully  fills  it  with  cedar- 
wood  oil.  When  full  he  sucks  up  the  blood  as  it  issues  from  the 
prick  in  the  finger.  The  blood  ascending  in  the  pipette  pushes 
the  column  of  oil  before  it,  and  inasmuch  as  it  only  comes  into 
contact  with  perfectly  smooth  walls  it  remains  fluid.  The  oil, 
being  lighter  than  the  blood,  is  then  separated  from  the  latter 
by  means  of  a  centrifuge  which  is  specially  adapted  for  the 
purpose,  and  at  the  same  time  the  plasma  is  separated  from  the 
blood  corpuscles.  In  this  way  three  sharply  defined  layers  are 
formed,  the  upper  oil  layer,  the  middle,  plasma  layer,  and  the 
lower  the  layer  of  corpuscles.  As  the  apparatus  is  calibrated, 
the  relative  volume  of  the  plasma  and  corpuscles  can  be  read 
off.  It  is  not  possible  to  detect  any  changes  in  the  corpuscles 
microscopically. 

Although  it  may  be  admitted  that  this  procedure  appears  to  be 
technically  difficult  to  carry  out,  it  remains  the  only  one  available 
up  to  the  present  which  fulfils  the  chief  requirements  of  clinical 
pathology  in  this  respect.  The  results  which  Koeppe  has  obtained 
up  to  the  present,  but  wdiich  are  not  very  numerous,  show  that 
the  total  volume  of  the  corpuscles  vary  between  51-1  and  o-i'S 
per  cent,  (average,  52-6  per  cent.). 

M.  and  L.  Bleibtreu  have  attempted  to  determine  the  relative 
1  Manufactured  by  Hugershoff,  Leipzig. 


24  INTRODUCTION 

volume  of  the  red  blood  corpuscles  to  the  plasma  indirectly. 
They  mixed  blood  with  varying  quantities  of  physiological 
saline  fluid,  •  and  determined  in  each  mixture  the  nitrogen 
content  of  the  fluid,  which  they  separated  from  the  cells  by 
sedimentation.  From  these  results  they  calculated  mathe- 
matically the  volume  of  the  serum  and  of  the  red  blood 
corpuscles.  Apart  from  the  fact  that  this  method  necessitates  a 
dilution  of  the  blood  with  physiological  saline  fluid,  it  is  far 
too  complicated  and  requires  too  large  a  quantity  of  blood  to 
justify  its  application  in  clinical  medicine.  Th.  Pfeiffer  has 
attempted  to  introduce  it  into  clinical  use  in  suitable  cases,  but 
so  far  has  not  obtained  definite  results.  It  can,  however,* be 
shown  that  the  relation  between  the  volume  percentage  of  the 
red  corpuscles  and  the  haemoglobin  content  is  not  constant.  For 
example,  in  acute  ansemias,  an  "  acute  "  swelling  of  some  of  the 
red  cells  has  been  observed  by  M.  Herz,  so  that  a  corresponding 
increase  in  the  total  volume  results,  without  any  increase  in  the 
quantity  of  hsemoglobin  taking  place.  This  deduction  has  received 
support  from  the  observations  of  von  Limberg,  Gerhard,  and 
others,  who  found  that  in  catarrhal  jaundice  the  red  cells  undergo 
a  considerable  increase  in  volume  under  the  influence  of  bile 
salts. 

As  has  been  stated  before,  the  most  valuable  indicator  of  the 
severity  of  an  ansemic  condition  is  to  be  obtained  by  the  estima- 
tion of  the  haemoglobin  content  of  the  blood.  Those  methods  of 
examination,  which  yield  neither  direct  nor  indirect  information 
with  regard  to  the  hsemoglobin  content,  are  only  of  importance 
on  account  of  the  possibility  of  throwing  light  on  the  special 
pathogenesis  of  the  individual  diseases  of  the  blood. 

A  very  large  amount  of  work  has  been  carried  out  by 
excellent  investigators,  especially  physiologists,  with  regard  to 
the  determination  of  the  reaction  of  the  blood. 

The  alkaline  reaction  Of  blood  cannot  be  demonstrated  by 
allowing  litmus  paper  to  be  moistened  by  fresh  blood  on 
account  of  the  colour  of  the  blood  itself.  Specially  sensitive 
litmus  paper  is  well  moistened  with  dilute  salt  solution,  and  the 


INTRODUCTION  25 

blood  is  then  allowed  to  (low  over  tlie  pajjei-;  and  lastly,  this  is 
washed  off  with  more  salt  solution.  Ft  is  very  diflicult  to 
determine  the  exact  degree  of  alkalinity,  it  is  sufhcient  for  the 
present  work  to  state  that  all  the  n(!W(!r  methods  depend  on 
a  laking  of  the  blood  and  sid)se<ni(!nt  titration  with  normal 
tartaric  acid  solution  against  rcsorcin  l^lue  jjaper  (litmoid).  In 
general  a  fair  quantity  of  blood  is  required  for  this  purpose,  e.g. 
5  to  8  c.c.  C.  S.  Engel,  however,  has  constructed  an  alkali- 
meter,  by  means  of  which  the  reaction  can  be  determined  with 
2-V  c.c.  of  blood. 

As  matters  stand  at  present  the  clinician  must  be  warned 
against  the  introduction  into  practice  of  uncertain  methods  of 
examination  which  yield  varying  results.  The  very  fact  that  the 
results  are  expressed  in  figures  awakens  a  false  appearance  of 
accuracy,  which  should  be  avoided  even  more  than  the  utilisation 
of  subjective  methods  of  examination. 

The  doctrine,  which  has  been  built  up  on  the  basis  of  the 
methods  referred  to,  with  regard  to  the  alkalinity  of  the 
blood  and  the  deductions  which  have  been  drawn  from  this 
doctrine,  have  been  attacked  in  a  very  convincing  manner  by 
Friedenthal.  Friedenthal  showed  that  the  method  which  is 
almost  always  employed  of  determining  the  reaction  by  means 
of  litmus  is  absolutely  unsuitable,  since  litmus  displaces  carbonic 
acid  from  the  carbonates,  and  in  this  way  the  alkali  is  set  free.  If 
the  test  is  carried  out  with  phenolphthalein,  a  neutral  reaction 
of  the  blood  can  be  clearly  demonstrated.  He  suggests  that  all 
the  biological  actions  and  phenomena  which  have  been  ascribed 
to  the  alkalinity  of  the  blood  and  blood  serum  may  be  explained 
by  ferment  action.  He  even  states  that  it  can  be  shown  that 
artificially  produced  alkalinity  of  the  blood,  even  when  very  slight, 
prevents  these  biological  actions. 

The  investigations  undertaken  by  Brandenburg  deserve 
special  mention.  These  show  that  it  is  necessary  to  distinguish 
between  the  alkali  which  is  combined  with  albumin  and  that 
which  is  combined  with  carbonic  acid.  These  two  combinations 
can  be  divided  from  one  another  by  dialysis,  since  the  latter  passes 


26  INTRODUCTION 

through  a  membrane,  while  the  former,  which  is  firmly  bound 
to  the  proteid  molecule,  is  prevented  by  the  colloid  from 
dialysing.  He,  was  able  to  show  that  the  dialysable  portion  of 
the  alkali  represented  a  very  constant  value  (corresponding  to 
about  60  mgrms.  of  NaOH),  while  the  non-dialysable  portion  was 
subjected  to  considerable  variations.  It  is  particularly  striking 
that  under  pathological  conditions,  even  when  considerable  altera- 
tions of  the  total  alkalinity  were  present,  the  amount  of  dialysable 
alkali — "  the  alkali  tension  " — remained  practically  unaltered. 

A  determination  which  will  probably  receive  greater  attention 
in  the  future  than  it  has  in  the  past  from  clinicians  is  that  of  the 
rapidity  of  coagulation.  Eesults  which  can  be  compared  with  one 
another  may  be  obtained  by  means  of  the  handy  apparatus 
constructed  by  Wright,  and  called  the  coagulometer.  In  certain 
conditions,  especially  in  the  acute  exanthemata  and  in  the  various 
forms  of  hsemorrhagic  diathesis,  the  rapidity  of  coagulation  of  the 
blood  is  distinctly  diminished.  The  coagulability  may  even  be 
abolished.  At  times,  on  the  other  hand,  a  definite  hastening  of 
the  coagulation  in  comparison  to  the  normal  can  be  determined. 
Wright  has  shown,  in  his  excellent  investigations,  that  the 
coagulability  can  be  influenced  by  drugs ;  calcium  chloride  and 
carbonic  acid  increase  the  coagulability ;  while  citric  acid,  alcohol, 
and  increased  respiratory  movements  diminish  it. 

Under  normal  conditions  the  blood  coagulates  in  from  three 
to  twenty  minutes.  Under  pathological  conditions  the  coagula- 
tion may  be  delayed  for  half  an  hour  to  one  hour,  and  at  times, 
as  in  hsemophylia,  even  to  eight  to  ten  hours  (Hayem). 

Hayem  has  repeatedly  called  attention  to  a  condition  which 
may  possibly  bear  some  relation  to  the  coagulability  of  the 
blood.  In  spite  of  the  coagulation  of  the  blood  having  taken 
place,  under  certain  conditions  the  separation  of  the  serum  from 
the  clot  only  occurs  to  a  slight  extent,  or  it  may  be  entirely 
absent.  Hayem  states  that  he  has  noticed  this  behaviour 
in  the  blood  of  patients  suffering  from  purpura  hsemorrhagica, 
protopathic  pernicious  ansemia,  the  cachexia  of  malaria,  and  some 
infectious  diseases. 


INTRODUCTION  27 

Large  qnantilieK  of  blood  nvc.  vcj\\\\yi:(\  I'oi' Uiose  observaLionH, 
such  as  are  not  iV(;(jiioiilly  to  Ih;  ol)l,;i,iiif;(l  in  ]ii'actice.  (Jortain 
precautions  wlilcli  liavo  bec^ii  loiiml  Lo  bo  of  iiso  in  tlio 
prejKiration  oi'  diplitheiiii,  antitoxin  must  bo  ;i(lo])ti(|,  in  order 
to  obtiijn  !i,s  liU'L^u  ii  yield  of  s(;iiini  as  jto.ssJble.  TlioHo  con- 
sist in  tlu3  collecting  the  blood  in  lon^isli  vessels,  which 
have  been  previously  thoroughly  cleansed,  and  more  especially 
freed  from  all  traces  of  fatty  substances.  If  the  clot  does  not 
retract  spontaneously  it  must  be  separated  from  the  wall  of  the 
vessel,  without  damaging  it,  by  means  of  a  flat  instrument,  like  a 
paper  knife.  If  no  separation  takes  place  in  the  cold  it  is  always 
possible  that  better  results  may  be  obtained  in  the  incubator. 

In  spite  of  all  care  and  the  application  of  all  the  contributory 
means,  it  sometimes  happens,  especially  when  pathological 
conditions  are  present,  that  not  a  trace  of  serum  can  be  gained 
from  a  fairly  large  quantity  of  blood.  Ehrlich  obtained  only 
about  100  c.c.  of  serum  from  22  kilos  of  blood,  from  a  horse 
which  had  previously  been  immunised  against  diphtheria  and 
had  yielded  extraordinarily  large  quantities  of  serum.  The  horse 
had  been  bled  to  death  on  account  of  a  tetanus  infection. 

It  is  quite  possible  that  this  condition  may  claim  the  atten- 
tion of  clinicians  in  future.  Hayem  has  attempted  to  distinguish 
protopathic  pernicious  anaemia  from  other  severe  forms  of 
anaemia  by  means  of  an  abnormal  separation  of  serum.  He  is 
further  of  opinion  that  a  bad  prognosis  is  justified  in  cachectic 
conditions  when  this  phenomenon  is  met  with. 

Mention  must  be  made  of  some  further  methods,  by  means  of 
which  the  resistance  of  the  red  blood  cells  toward  external  noxes 
of  various  kinds  can  be  tested. 

Landois,  Hamburger,  and  von  Limbeck  determined  that 
concentration  of  a  salt  solution  ("isotonic  concentration" 
Hamburger)  in  which  the  red  blood  corpuscles  are  preserved,  and 
that  which  causes  the  haemoglobin  to  issue  from  tlie  stroma. 
They  found  that  the  lower  the  concentration  of  the  salt  solution  is, 
in  which  the  erythrocytes  still  remain  unaltered,  the  higher  is 
their  resistance. 


28  INTRODUCTION 

Bettmann  has  employed  Lugol's  solution  in  varying  con- 
centrations with  great  advantage  in  these  determinations,  since 
the  influence  on  the  erythrocytes  exerted  by  the  salt  solution 
can  be  controlled  very  clearly  under  the  microscope.  Eosin  and 
Bibergeil  have  experimented  with  various  stains,  including 
methylene-blue  and  neutral  red,  with  a  similar  object. 

Laker  has  tested  the  erythrocytes  as  to  their  power  of 
resistance  toward  electric  discharges  from  Leyden  jars,  and  has 
measured  this  resistance  by  recording  the  number  of  shocks 
which  can  be  passed  through  the  sample  of  blood  without 
producing  a  damage  to  the  cells. 

Eosin  and  Bibergeil  have  noticed  that  fresh  blood  of  healthy 
persons  enclosed  in  the  moist  chamber,  without  the  addition  of  any 
chemicals  or  the  application  of  other  extraneous  means,  retains 
its  morphological  components  in  an  intact  condition  considerably 
longer  than  the  blood  of  anaemic  persons  does.  They  consider 
that  this  is  evidence  of  the  smaller  resistance  of  anaemic  as 
compared  with  healthy  blood. 

The  study  of  the  hsemolysins  has  proved  itself  to  be  of 
special  importance  to  this  question.  H.  Sachs'  experiments  with 
the  poison  of  the  cross  spider  have  revealed  that  the  blood  of 
chickens  which  have  just  been  hatched  is  absolutely  insensitive 
toward  arachnolysin,  while  the  blood  of  adult  hens  is  extremely 
sensitive  toward  this  substance. 

In  order  to  obtain  a  true  conception  of  the  resistance  of  the 
erythrocytes,  it  would  naturally  be  necessary  to  test  the  effect 
not  only  of  every  possible  mixture,  but  also  of  every  form  of 
physical,  mechanical,  thermic,  and  other  stimulus.  It  might 
be  found  that  a  special  kind  of  erythrocyte  A,  which  shows 
a  much  smaller  degree  of  resistance  toward  a  certain  chemical 
substance  than  a  second  kind  of  erythrocyte  B,  would  behave 
in  an  absolutely  similar  manner  toward  another  form  of 
stimulus. 

Clinical  medicine  has  not  benefited  materially  up  to  the 
present  by  these  methods.  One  thing,  however,  is  certain,  namely, 
that  in  some  diseases,  such  as  anaemia,  hsemoglobinuria,  and  after 


rNTRODUCTION  29 

Bonic  forms  of  poisoning,  the  resistance  of  the  rod  blood  corpuscles 
is  ascertainably  reduced. 

Closely  related  to  these  methods,  which  only  affect  the  red 
blood  corpuscles,  is  tlie  metliod  of  determining  tlio  freezing-point 
depression  of  the  blood  as  a  whole  and  of  the  serum.  This  is 
known  as  cryoscopy. 

The  cryoscopy  of  the  blood  is  carried  out  in  the  same 
manner  and  with  the  same  apparatus  as  that  of  the  urine.  The 
information  which  has  been  gained  with  regard  to  the  molecular 
concentration  of  the  blood  is  extremely  meagre,  and  has  not 
yielded  any  valuable  results,  more  especially  for  the  pathology  of 
the  blood.  At  all  events,  this  method  has  not  taught  anything 
which  had  not  been  ascertained  previously  by  means  of  the  deter- 
mination of  the  specific  gravity. 


CHAPTER   II 

THE  MORPHOLOGY  OF  THE  BLOOD 

^.—METHODS  OF  EXAMINATION 

A  GLANCE  through  the  history  of  the  microscopy  of  the  blood 
shows  that  this  has  been  divided  into  two  epochs.  In  the  first, 
which  has  been  distinguished  especially  by  the  work  of  Virchow 
and  Max  Schultze,  a  number  of  positive  facts  were  rapidly 
collected,  and  the  various  forms  of  leukaemia  were  recognised. 
But  after  this  no  further  progress  was  made  for  several  decennia. 
This  stand-still  was  due  to  the  fact  that  the  observers  limited 
themselves  to  the  study  of  the  blood  in  its  fresh  condition. 
All  that  was  to  be  seen  with  the  assistance  of  these  simple 
means  had  very  soon  been  thoroughly  exhausted  by  these 
excellent  observers.  That  these  methods  were  insufficient  can 
best  be  shown  by  the  history  of  leucocytosis,  which  according 
to  Virchow's  teaching  was  supposed  to  be  brought  about  by  an 
increased  production  of  cells  by  the  lymphatic  glands.  The  same 
is  seen  in  the  fact  that  leucocytosis  and  early  leukaemia  were  not 
sharply  differentiated,  and  the  diagnoses  were  made  on  the  basis 
of  simple  numerical  determinations.  It  was  only  after  Ehrlich 
had  introduced  the  new  method  of  examining  stained  dry  pre- 
parations that  the  histology  of  the  blood  entered  on  its  second 
era.  We  are  indebted  to  Ehrlich  for  an  exact  differentiation 
of  the  various  forms  of  white  blood  corpuscles,  for  a  rational 
definition  of  leukaemia,  for  the  knowledge  of  polynuclear  leuco- 
cytosis, for  the  knowledge  of  the  signs  of  de-  and  re-generation 
of  the  red  blood  corpuscles,  and  for  their  breaking  down  in 
haemoglobinsemic  processes.  The  same  means  of  advance  have 
obtained  in  the  subject  of  the  microscopy  of  the  blood  as  have 


THE  M()IMM10L()(;y  OK  THE   IJLOOI)     :>,] 

been  witnessed  in  the  othor  depiirlnicnt.s  oi'  noiniul  und  paLliologicul 
histology ;  improvement  in  techni([ue  must  first  Vjo  achieved  before 
material  advances  in  knowledge  can  be  luiived  ;it.  I'"or  this 
reason  it  is  difficult  to  understand  how  certain  observ(;rs  still 
recommend  the  old  methods,  and  claim  that  a  diagnosis  can  be 
made  in  all  cases  from  the  examination  of  fresh  blood  specimens. 
It  may  be  admitted  tliat  this  wcjuld  not' 1)0  surprising,  since  the 
most  important  points  have  already  been  explained  by  means 
of  the  new  methods.  ]>ut  the  recognition  of  the  more  difficult 
cases,  c.ij.  certain  rare  forms  of  antemia,  and  for  the  recognition 
of  definite  kinds  of  cells,  such  as  myelocytes,  mast  cells,  etc., 
stained  preparations  are  indispensal)le,  as  every  experienced 
hiematologist  knows.  The  object  of  the  examination,  moreover, 
is  not  to  facilitate  a  rapid  diagnosis,  but  rather  to  enable  an 
exact  study  of  the  details  characterising  the  blood  to  be  carried 
out,  which  cannot  be  ascertained  from  fresh  specimens.  It  may 
with  safety  be  claimed  that  at  present  it  is  possible  to  see  all 
the  characteristics  of  the  blood,  save  those  of  the  formation  of 
rouleaux  and  of  the  amoeboid  movements  of  the  white  corpuscles,  in 
stained  dry  preparations  as  well,  if  not  better,  than  in  the  fresh 
specimens  ;  while  it  must  be  admitted  that  there  are  many  important 
details  which  can  only  be  rendered  visible  by  means  of  staining 
fixed  preparations,  and  which  remain  invisible  in  fresh  specimens. 

Examination  with  the  assistance  of  the  so-called  "  dark  field 
illumination "  forms  a  valuable  extension  of  the  methods  of 
studying  the  blood,  especially  in  its  fresh  condition.  This  was 
first  employed  for  this  purpose  by  Dietrich.  It  has  become 
possible  with  its  assistance  to  demonstrate  certain  morphological 
details,  e.g.  shadows  in  the  corpuscles,  more  clearly  than  had 
been  done  previously,  while  even  some  biological  processes,  such 
as  haemolysis,  can  be  rendered  directly  visible  by  means  of  the 
dark  field  illumination.  The  special  morphology  of  the  blood 
cell,  however,  has  not  been  advanced  by  this  method,  nor  by  the 
method  of  examining  with  the  aid  of  nltra-violet  rays  (Grawitz 
and  Griineberg). 

As  far   as  the   purely  technical   or    practical    aspect    of    the 


32  ANEMIA 

question  is  concerned,  the  examination  of  stained  dry  films  is 
undoubtedly  much  more  convenient  than  that  of  fresh  specimens. 
The  former  enables  the  observer  to  be  independent  with  regard  to 
place  and  time.  Fixed  specimens  may  be  put  aside  for  months 
without  any  special  precautions,  and  then  studied  closely  under 
the  microscope.  The  examination  of  one  specimen  can  be  con- 
tinued for  any  length  of  time,  and  can  be  repeated  at  any 
future  date.  On  the  other  hand,  the  examination  of  the  blood 
in  the  fresh  condition  is  only  possible  at  the  bedside,  and  must 
be  completed  rapidly,  since  the  blood  changes  quickly,  by 
clotting,  by  destruction  of  the  white  cells,  etc.,  so  that  an  ex- 
haustive study  cannot  be  undertaken  at  all.  An  additional 
advantage  of  the  former  consists  in  the  fact  that  the  making 
and  staining  of  dry  blood  films  may  be  regarded  as  one  of  the 
easiest  and  most  convenient  of  all  the  methods  of  clinical 
histology.  It  is  therefore  advisable  to  describe  the  technique 
in  detail  in  this  place,  in  order  to  awaken  wide  interest  for  this 
mode  of  examination. 

It  is  further  found  advisable  to  describe  in  this  place  the 
application  of  stained  dry  specimens  for  the  determination  of  the 
important  numerical  relation  between  the  red  and  white  blood 
corpuscles,  and  of  the  proportional  percentages  of  the  various 
forms  of  white  corpuscles. 

It  is  absolutely  necessary  that  the  investigator  should  be  able 
to  make  a  perfect,  uniform  film.  Quadratic  ocular  diaphragms 
(Ehrlich-Zeiss)  are  essential.^  These  either  represent  a  complete 
series,  so  that  the  sides  of  the  square  having  measurements  in 
the  ratio  of  1:2:3  .  .  .  10,  would  give  segments  of  the  field 
in  the  ratio  of  1  :  4  :  9  .  .  .  :  100,  or  take  the  form  of  the  more 
handy  eye-piece,  devised  by  Ehrlich  and  constructed  by  Leitz, 
which  possesses  a  neat  mechanical  appliance  by  means  of  which 
a  centrally  situated,  square  segment  of  the  field  of  a  desired  size 
can  be  interposed.  The  eye-piece  is  used  in  the  following  manner. 
A  normal  blood  preparation  is  examined  by  first  counting  the 
white  blood  corpuscles  as  seen  in  the  field  when  a  No.  10  dia- 
^  These  square  eye-pieces  are  not  frequent  in  this  country. — (The  Translator). 


phra<^ni  (or  the  Beginont  TOO  of  tlio  eye-piece)  is  interposed.  Next 
the  cliM,Y)hragm  No.  1  is  interposed  so  that  only  one-hnndredth 
part  of  the  (ield  is  exposed,  and  in  tliis  fifild  the  nunihei-  of  red 
blood  cells  are  counted.  This  is  done  witliout  shifting  the  speci- 
men. Next,  another  part  of  the  specimen  is  chosen  at  random, 
and  the  count  repeated ;  in  each  case  only  one  hundredth  or 
one  twenty-fifth  of  the  field  employed  for  the  white  cell  count 
is  used  for  the  red  cell  count.  About  100  such  counts  are  made 
in  each  specimen.  The  number  of  red  cells  is  then  multiplied  by 
100,  and  compared  to  the  number  of  white  cells  counted.  When 
the  white  cells  are  very  numerous  and  the  counting  in  a  large 
segment  becomes  difficult,  a  smaller  diaphragm  is  employed,  such 
as  81,  64,  49,  and  so  on. 

The  important  determination  of  the  percentage  proportions  of 
the  various  forms  of  leucocytes  is  carried  out  by  noting  the  numbers 
of  each  kind  in  a  series  of  several  hundred  cells.  This  can  be 
done  by  an  experienced  individual  in  less  than  a  quarter  of  an 
hour. 

(a)  Making  a  Dry  Specimen. 

For  the  purpose  of  making  perfect  dry  films,  it  is  of  especial 
importance  to  use  cover-glasses  of  a  particular  kind.  The  cover- 
glasses  should  not  be  thicker  than  0'08  to  O'lO  mm. ;  the  glass 
should  not  be  brittle,  it  should  have  no  defects,  and  it  must  be  of 
such  a  quality  that  it  will  bend  to  a  considerable  extent  without 
breaking.  The  slightest  roughness  of  the  glass  renders  it  useless 
for  the  purpose.  The  cover-glasses  must  be  subjected  to  a 
scrupulous  cleansing,  and  must  be  absolutely  freed  from  all  traces 
of  fat.  For  ordinary  purposes  it  is  sufficient  to  immerse  the 
glasses  in  aether  for  thirty  minutes,  without  allowing  them  to 
overlap,  and  then  to  wipe  them  with  an  old  soft  linen  or  cambric 
cloth.  They  are  then  dipped  into  alcohol  for  a  few  minutes,  and 
are  again  dried  in  the  same  manner  as  they  were  after  immersion 
in  aether.  They  should  then  be  placed  in  a  dust-tight  glass  bottle 
or  box  until  required.  The  fact  that  these  cover-glasses  are  cut 
out  of  a  large  cylinder  and  not  out  of  a  flat  plate  of  glass  shows 
3 


34 


ANAEMIA 


that  they  are  the  only  kind  which  would  allow  of  the  formation  of 
a  capillary  space  between  them  when  superimposed  on  one  an- 
other, in  which  the  blood  can  spread  out  spontaneously.  The 
slightest  unevenness  or  brittleness  of  the  glass  would  render  it 
impossible  for  the  curve  in  the  one  to  correspond  suJEiiciently 
exactly  to  the  curve  in  the  second.  It  is  only  when  the  glasses 
are  of  this  quality  that  it  becomes  possible  to  slide  the  one 
from  the  other  without  using  such  force  as  would  destroy  the 
film. 

The  cover-glasses  must  be  held  by  means  of  forceps  ^  in 
order  to  avoid  any  soiling,  and  especially  any  contamination  of 
the  blood  by  moisture   of  the   finger.     The  lower  glass  is  best 

held  in  a  pair 
of  forceps  pro- 
vided with  a 
catch  and  broad 
fiat  points  (a). 
The  inside  of 
these  points 
can  be  lined  to 
^i»-  1-  the    extent    of 

about  3  cms.  from  the  tips  with  leather  or  English  blotting- 
paper.  The  other  cover-glass  is  best  held  in  a  pair  of  forceps 
(&)  with  a  good  spring  and  smooth  but  very  sharp  points.  These 
forceps  will  enable  the  operator  to  catch  hold  of  the  cover-glass 
even  when  it  is  lying  on  a  perfectly  smooth  surface.  The  lower 
cover  is  seized  with  the  clamp  forceps,  fixed  and  held  in  the  left 
hand.  The  second  glass  is  taken  up  in  the  forceps  (b)  with  the 
right  hand,  and  applied  to  the  drop  of  blood  issuing  from  the  prick 
in  the  finger.  The  cover-glass  must  pick  up  the  blood  without 
touching  the  finger  itself.  Next  the  cover-glass  in  the  right- 
hand  pair  of  forceps  is  carried  rapidly  to  the  other  and  allowed 
to  fall  gently  on  it.  The  blood  then  distributes  itself  in  an  absol- 
utely uniform  capillary  layer,  without  the  application  of  any 
pressure,  provided  that  the  cover-glasses  are  suitable.  The  upper 
^  Klonne  and  Miiller,  Berlin,  make  the  forceps,  as  devised  by  Ehrlich. 


THE  MORPITOr.OGY  OF  TFTE  BLOOD     .',5 

glass  is  then  Hoiz(3(l,  cither  with  two  iingei's  ol'  th(;  lif^lit  h.'ind,  oi' 
better  still  with  the  forceps  (b),  and  is  carefully  slid  oil"  tlio  lowor 
cover-glass,  which  is  still  held  by  the  clamped  forcejjs,  but  without 
pressing  or  raising  it  (sec  Fig.  1).  v\s  a  rule  only  the  lower  glass 
yields  a  perfectly  uniform  smear,  but  at  tiuK^s  both  arc;  utilisable. 
During  the  process  of  drying  in  the  air,  which  takes  about  ten  to 
thirty  seconds,  it  is  of  course  necessary  to  protect  the  cover-glasses 
from  moisture,  such  as  that  derived  from  the  breatli  of  persons  in 
the  vicinity. 

The  size  of  the  film  on  the  cover-glass  depends  on  the  size  of 
the  drop  which  has  been  picked  up.  The  smaller  this  has  been, 
the  smaller  will  be  the  surface  over  which  the  blood  will  distribute 
itself.  Large  drops  are  absolutely  useless,  if  they  cause  the  one 
cover-glass  to  swim  on  the  other  instead  of  merely  sticking  them 
together. 

The  directions  for  this  method  may  appear  to  be  somewhat 
complicated,  but  a  little  practice  will  show  that  the  technique  can 
be  easily  acquired.  The  details  have  been  described  minutely, 
because  the  author  frequently  sees  specimens  which  he  considers 
to  be  quite  unsuited  for  the  purpose,  although  they  have  been 
made  by  men  who  have  given  special  attention  to  the  study  of 
hsematology.^ 

Jancso  and  Eosenberger  have  published  the  details  of  another 

^  Translator's  Note. — A  considerable  number  of  English  investigators  dispense 
with  the  use  of  cover-glasses  altogether.  Slides  of  the  best  quality  are  employed 
and  cleaned  with  utmost  care.  Boiling  in  sulphuric  acid  or  nitric  acid,  subsequent 
rinsing  in  distilled  water,  washing  in  alcohol  and  storing  in  mixtures  of  alcohol 
and  aether  yield  good  results.  Wright  advises  polishing  with  very  fine  emery  cloth, 
stretched  on  a  wooden  block  before  use.  The  drop  of  blood  is  applied  to  tlie  slide, 
and  is  spread  over  the  whole  length  by  means  of  a  second  slide.  Before  this  is 
done  it  is  necessary  to  select  a  second  slide,  which  "dances,"  i.e.  which  shows  a  just 
perceptible  concavity  of  one  of  its  ends.  The  concave  surface  is  then  gently  and 
lightly  pushed  up  tlie  slide  bearing  the  drop  of  blood  until  the  blood  runs  toward 
the  edge  by  capillary  attraction.  The  slide  is  then  gently  drawn  downwards, 
when  it  will  be  found  that  the  blood  follows  it.  Under  no  circumstances  may  the 
slide  be  drawn  over  the  blood.  AV right  performs  this  drawing  in  short  regular 
jerks,  so  that  the  smear  appears  as  a  series  of  thicker  and  thinner  transverse  lines 
of  blood  right  down  the  lower  slide.  Some  workers  have  also  used  a  thread  of 
silk  for  the  purpose  of  drawing  the  blood  down  the  slide. 

The  advantage  of  dispensing  with  the  cover-glass  is  obvious.  In  the  first  place, 
it  is  difficult  to  secure  cover-glasses  which  are  reliable  ;  next,  they  are  much  more 


36  ANiEMIA 

method  of  making  fixed  blood  smears.  This  method  has  been 
employed  by  a  number  of  investigators.  The  drop  of  blood  is 
picked  up  on  the  edge  of  one  cover-glass  from  the  finger,  and 
the  edge  of  this  cover-glass  is  then  drawn  gently  over  the  full 
length  of  a  second  cover-glass.  With  practice  very  nice  thin 
smears  can  be  obtained  in  this  way,  which  dry  rapidly  in  the 
air. 

After  the  specimens  have  dried  thoroughly  they  may  be 
stored  between  layers  of  filter  paper  in  glass  vessels  provided 
with  properly  fitting  stoppers.  For  important  cases,  when  it 
is  desirable  to  preserve  the  smears  for  a  considerable  time,  it 
may  be  wise  to  protect  the  smear  from  the  damaging  effect  of 
the  atmospheric  air  by  covering  it  with  a  layer  of  hard  paraffin. 
Before  the  films  can  be  fixed  and  stained  it  is  then  necessary 
to  remove  the  wax  by  dissolving  it  in  toluol  or  xylol.  It  is,  of 
course,  essential  to  keep  the  films  in  the  dark. 

The  procedure  may  be  modified  in  a  number  of  ways 
according  to  the  object  of  the  examination.  For  example,  for 
the  detection  of  blood  parasites  it  is  advisable,  according  to 
Eobert  Koch,  to  use  very  large  drops  of  blood.  The  blood 
cells,  which  are  of  minor  importance  in  these  cases,  may  be 
dissolved,  and  the  detection  of  the  parasites  may  be  rendered 
much  more  easy  by  the  use  of  a  considerable  quantity  of 
blood. 

(b)  Fixing  a  Dry  Specimen. 

All  methods  of  staining  blood  cells  require  a  preliminary 
fixation  of  the  albuminous  substances  in  the  blood.  General 
directions  for  fixation  cannot  be  given,  since  the  intensity  of 
the  same  must  depend  on  the  choice  of  the  method  of  staining. 

flifficult  to  clean  than  slides,  and  are  at  the  best  of  times  liable  to  break.  Further, 
tlie  slide  yields  a  much  larger  surface  for  examination,  which  may  be  of  great  im- 
portance, especially  when  it  is  difficult  or  impossible  to  secure  another  specimen 
of  blood.  The  slides  keep  well,  and  are  examined  without  any  cover-glass,  the 
cedar-wood  oil  being  applied  directly  to  the  film  and  the  objective  immersed  in 
the  oil.  The  oil  can  be  removed  from  the  smear  without  damaging  the  latter  by 
means  of  xylol  or  other  solvent,  if  applied  with  care.  This  should  be  done  after 
the  examination  is  completed,  and  not  left  until  a  future  occasion. 


THE  MORPHOLOGY  OF  THE   HLOOI)     37 

Comparatively  f-nuill  (logrees  of  hardening  sulHce  wIkmi  the 
staining  is  caniod  out  with  watery  sohitions,  sucii  as  the 
triacid  solution.  This  may  he  a(;hieved  hy  allowing  various 
agents  to  act  for  a  short  time,  and  in  not  too  intense  a  manner. 
Other  methods,  which  inchule  the  use  of  strong  acids  or  which 
are  carried  out  with  sohitions  containing  free  alkalies,  ref[uire 
that  the  structure  should  he  fixed  by  a  much  stronger  action 
of  the  fixatives.  It  is  just  as  important  to  avoid  over  as 
under  fixation.  It  is  quite  easy  to  determine  the  optimum 
fixation  for  each  of  the  few  staiidng  solutions  which  are  in 
use. 

The  following  means  of  fixation  may  be  employed  : — 

1.  DRY  HEAT. 

For  this  purpose  a  simple  copper  plate  placed  on  a  stand 
is  heated  at  one  end  by  means  of  a  Bunsen  burner.  After 
the  flame  has  been  burning  for  some  little  time  it  may  be 
assumed  that  the  plate  has  acquired  a  certain  degree  of  con- 
stancy of  temperature.  It  will,  of  course,  be  hottest  at  the 
burner  end,  and  least  hot  at  the  other  end.  By  allowing  water, 
toluol,  xylol,  and  other  fluids  to  drop  on  the  plate,  the  observer 
can  easily  ascertain  which  portion  of  the  plate  has  approximately 
the  temperature  at  which  the  various  fluids  boil. 

Victor  Meyer's  apparatus,  which  is  much  used  by  chemists, 
is  more  suitable  for  this  purpose.  A  modification  adapted  to 
the  fixing  of  specimens  takes  the  form  of  a  small  copper  kettle, 
the  cover  of  which  is  a  thin  copper  plate  having  only  one 
opening  for  the  transmission  of  the  steam  pipe.  If  a  small 
quantity  of  toluol  is  allowed  to  boil  in  the  kettle  for  a  few 
minutes,  it  may  be  assumed  that  the  temperature  of  the  copper 
lid  is  also  between  107°  and  110°  C. 

It  is  sufficient  for  specimens  which  are  to  be  stained  by  the 
ordinary  watery  solutions  to  expose  the  cover-glasses  to  a 
temperature  of  about  110°  for  a  half  to  two  minutes.  When 
differential  staining  (such  as  the  eosin-aurautia-nigrosin  mixture) 


38  ANEMIA 

is  to  be  employed,  it  may  be  necessary  to  expose  them  for  longer 
periods  or  to  higher  temperatures. 

2.  CHEMICAL  MEANS. 

(a)  Nikiforoff  advised  fixing  the  smears  in  mixtures  of  equal 
parts  of  absolute  alcohol  and  aether  for  two  hours,  in  order  to 
obtain  good  triacid  staining.  Specimens  fixed  in  this  manner, 
however,  are  not  so  fine   as  those  fixed  by  heat. 

(5)  Absolute  alcohol  fixes  dry  smears  within  five  minutes 
sujfficiently  for  subsequent  staining  by  Chenzinsky's  solution 
or  by  hsematoxylin-eosin  solution.  In  some  cases,  when  it  is 
desirable  to  examine  the  specimen  quickly,  it  may  be  advisable 
to  boil  the  dried  cover-glass  for  one  minute  in  a  test  tube 
with  absolute  alcohol. 

(c)  For  Griemsa  staining  it  is  advisable  to  fix  in  absolute 
methyl  alcohol.  If  this  is  undertaken  immediately  after  the 
drying  the  fixation  takes  from  three  to  five  minutes,  while 
if  it  is  carried  out  on  the  following  day  it  only  takes  two 
minutes. 

(d)  Formol  was  first  employed  by  Benario  in  1  per  cent, 
alcoholic  solutions  for  the  fixation  of  blood  specimens.  The 
fixing  is  completed  in  one  minute,  and  may  be  used  for  the 
demonstration  of  granulations.  Benario  recommends  it  especially 
for  staining  with  hsematoxylin-eosin. 

Schiiffner  obtained  beautiful  results  by  fixing  his  blood  smears 
in  1  per  cent,  formol  solution  to  which  from  5  to  10  per 
cent,  of  glycerine  had  been  added. 

For  certain  forms  of  staining  the  fixation  is  carried  out 
simultaneously  with  the  staining  (see  below). 

It  must  be  understood  that  these  methods  are  described  as 
the  most  suitable  for  blood  examination  in  general.  For  special 
purposes,  e.g.  the  demonstration  of  mitosis,  of  blood  platelets, 
etc.,  the  fixation  methods  generally  employed  in  other  branches 
of  histology  may  be  used  with  advantage.  These  include 
perchloride  of  mercury,  osmic  acid,  and  Fleming's  solution  ioiter 
alia. 


THE  MOUPIIOLOGY  OF  TTTK   IJLOOT)     .39 

(c)  staining  a  Dry  Specimen. 

Staining  methods  may  be  classified  according  to  the  purpose 
for  which  they  are  used. 

In  the  first  place,  stains  are  employed  for  tin;  purpose  of 
obtaining  rapid  information  of  a  general  character.  This  may 
be  attained  by  solutions  which  stain  both  tlie  haemoglobin  and 
the  nuclei  (hasmatoxylin-eosin,  ha^matoxylin-orange). 

In  the  next  place,  it  is  at  times  desirable  to  have  a  staining 
which  only  afi'ects  one  special  form  of  cell  in  a  characteristic 
manner,  such  as  the  eosinophile  cells,  the  mast  cells,  or  bacteria. 
This  is  termed  "  single  staining,"  and  is  carried  out  in  accordance 
with  the  principle  of  maximal  decolorisation  (see.  E.  Westphal). 

In  the  last  place,  there  is  the  so-called  panoptic  staining, 
i.e.  staining  which  affects  as  many  elements  as  possible,  and 
which  makes  use  of  the  greatest  variety  of  colours.  These 
methods  are  naturally  of  considerable  interest  for  exhaustive 
examinations.  It  is  necessary  when  they  have  been  employed 
to  utilise  high  magnification  for  the  study  of  the  specimens,  but 
apart  from  this  fact  the  methods  yield  more  information  with 
regard  to  the  condition  of  the  blood  than  any  other.  In  order 
to  obtain  the  greatest  possible  degree  of  differentiation,  it  will 
be  found  that  double  staining  is  usually  not  sufficient,  but  that 
it  is  necessary  to  use  three  colours  which  contrast  from  one 
another  as  much  as  possible.  Formerly,  the  various  stains  were 
applied  successively  for  this  purpose.  But,  as  every  one  who  has 
employed  these  methods  knows,  it  is  exceedingly  difficult  to 
obtain  constant  results  in  this  way,  for  even  w^hen  the  directions 
with  regard  to  the  length  of  time  of  staining  and  the  con- 
centration of  the  solutions  are  followed  with  the  most  minute 
care,  it  is  impossible  to  rely  on  the  results. 

On  the  other  hand,  the  methods  of  simultaneous  or  combined 
staining  offer  undoubted  technical  advantages.  Improvements 
in  technique  are  of  considerable  importance  for  the  development 
of  the  histology  of  the  blood.  Since  it  appears  that  there  is 
some   want   of   clearness   in  the    mind   of   some   observers   with 


40  ANEMIA 

regard   to  the   principles,  a  short   description   of   the   theory  of 
differential  simultaneous  staining  may  be  of  use. 

For  this  purpose   a   simple  example  will   be   selected.     This 
is  the  employment  of  picro-carmine,  i.e.  of  a  mixture  of  neutral 
ammonium-carmine  and  a  salt  of  picric  acid.     If  a  tissue  which 
is  rich  in  protoplasm  be  stained  with  carmine,  the  stain  appears 
to  be  fairly  diffuse,  even  though    the  nuclei  become   prominent. 
But  if  picrate  of  ammonium  of  the  same  concentration  be  added 
to  the  solution,  the  staining  gains  greatly  in  definition,  by  some 
portions  appearing  pure  yellow  and  others  pure   red.     The   best 
known  example  of  this  is  the  staining  of  muscle  by  picro-carmine. 
In  this  case  the  muscle  substance  is  stained  pure  yellow,  while 
the  nuclei  take  on  a  red  colour.     Now,  if,  instead  of  adding  the 
picrate  of  ammonium,  the   experimenter   uses   a  dye  containing 
more  nitro   groups,  such   as   the  ammonium  salt   of   hexa-nitro- 
diphenylamin,  the  carmine  staining  will  be  prevented  altogether. 
All  the  elements  in  this  case  take  on  the  pure  colour  of  aurantia, 
no  matter  how  long  the  stain  is  allowed  to  act.     The  explanation 
is  very  simple.     Myosin  possesses  a  greater  affinity  for   picrate 
of   ammonium   than   for  carmine,  and   therefore   combines   with 
the  yellow  dye  contained  in   the  mixture   of  both  stains.     This 
combination  removes  the  possibility  of  it  taking  up  any  carmine. 
The  nuclei,  however,  possess  a  greater  affinity  for  carmine,  and 
therefore  stain  red  in  this  process.     But  if  a  nitro  dye  be  added 
to  the  carmine  solution,  which  possesses  a  greater  chemical  affinity 
for  all  the  elements  of  the  tissue,  and  even  for  the  nuclei  than 
the  carmine  itself,  the  sphere   of  action  of  the  carmine   will  be 
more  and  more  limited,  until  when  a  very  strongly  acting  nitro 
stain — the    liexanitro  compound — is   used,  it   will   be   prevented 
altogether.     Connective  tissue,  bone  substance,  and  similar  tissues, 
however,  behave  in  a  different  manner  toward  the  picro-carmine 
mixture.     In  this  case    the   diffuse  staining  is   solely  dependent 
on  the   concentration  of  the   carmine,  and   is  not  influenced  by 
the  employment  of  a  chemical  antagonist.     It  therefore  is  only 
possible  to   obtain  a  limitation    of  this  staining  by  diluting  the 
stain,   and   no   addition   of   a   dye   stuff"    possessed    of    opposite 


THE  MORrH()I.()(iV  OF  TIIK   IM.OOI)      11 

characters  will  make  any  difference.  Tliis  example  of  tissue 
staining  may  be  regarded  as  a  mechanical  attraction  of  the 
colour  by  the  tissues,  and  not  as  a  chemical  combination.  It 
may  therefore  be  stated  that  a  chemical  staining  may  be 
recognised  by  the  fact  that  it  reacts  to  chemical  antagonists, 
and  tliat  a  meclianical  staining  reacts  to  physical  modifications. 
This  statement,  however,  is  true  only  as  long  as  pure  neutral 
solutions  of  stains  are  employed.  All  additions,  such  as  those 
of  acids  and  alkalies,  which  could  alter  the  chemical  behaviour 
of  the  tissue,  or  which  could  diminish  or  increase  the  affinity 
of  the  tissues  to  the  dyes,  would  also  interfere  with  this  test. 
From  this  view  it  may  be  deduced  that  all  double  staining 
methods,  which  can  be  employed  by  means  of  successive  stainmg, 
can  be  advantageously  substituted  by  combination  staining, 
provided  that  it  can  be  proved  that  the  staining  depends  on 
a  chemical  combination.  And,  conversely,  all  those  methods  of 
double  staining  which  can  only  be  obtained  by  successive  staining 
must  be  dependent  on  mechanical  processes. 

Only  pure  chemical  staining  processes  are  employed  for  the 
purpose  of  staining  dry  blood  films,  and  the  application  of 
polychromatic  combination  staining  is  therefore  possible  in  all 

cases. 

The     following     combinations     are      available      for      blood 

preparations  : — 

1.  Combination  Staining  with  Acid  Dyes. — The  best- 
known  example  of  this  is  the  eosin-aurantia-uigrosin  mixture, 
with  which  the  hiemoglobiu  stains  orange,  the  nuclei  black,  and 
the  acidophile  granules  red. 

2.  Mixtures  of  Basic  Dyes. — It  is  a  simple  matter  to 
prepare  mixtures  of  two  dye  bases.  The  most  suitable  of  these 
are  fuchsin,  methyl-green,  methyl-violet,  methyleue-blue,  and 
pyronin.  On  the  other  hand,  it  is  somewhat  difficult  to  form  a 
mixture  of  three  of  these  substances,  and  this  can  only  be  done 
successfully  by  paying  minute  attention  to  the  quantitative 
relationships.  The  following  may  be  employed  for  this  purpose  : 
— fuchsin,  Bismarck-brown,  chromic-green. 


42  ANJEMIA 

3.  Neutral  Mixtures.  —  These  mixtures  were  first 
introduced  by  Ehrlich  into  use  for  the  histology  of  the  blood, 
and  for  general  histology.  They  have  been  found  to  be  of 
considerable  importance  and  claim  careful  consideration. 

Neutral  staining  depends  on  the  fact  that  nearly  all  basic 
dyes  (i.e.  the  salts  of  dye  bases,  e.g.  rosanilin  acetate)  enter  into 
combination  with  acid  dyes  (i.e.  salts  of  dye  acids,  e.g.  picrate 
of  ammonium)  to  form  what  is  known  as  neutral  dyes  (e.g. 
rosanilin  picrate).  Their  use  is,  however,  rendered  difficult  by  the 
fact  that  they  are  very  little  soluble  in  water.  It  was  only  after 
Ehrlich  had  shown  that  certain  series  of  the  neutral  dyes  are 
freely  soluble  in  the  presence  of  an  excess  of  acid  dyes  that 
their  use  was  rendered  practically  possible;  in  this  way  stable 
solutions  of  varying  concentration  of  these  dyes  can  be  prepared. 
The  most  suitable  basic  dyes  for  this  purpose  are  those  which 
contain  a  so-called  ammonium  group,  and  especially  methyl-green, 
methylene-blue,  amethyst-violet  ^  (tetra-ethyl-safranin-chloride), 
and,  under  certain  conditions,  pyronin  and  rhodamin.  In 
contradistinction  to  these,  those  dyes  which  form  the  members 
of  the  triphenyl-methane  series  are  on  the  whole  but  little 
suitable  for  this  purpose,  with  the  exception  of  methyl-green. 
These  include  fuchsin,  methyl-violet,  Bismarck-brown,  phosphin, 
and  indacine.  The  most  suitable  acid  dyes  for  the  purpose 
of  forming  the  neutral  dyes  are  more  especially  those  highly 
soluble  salts  of  the  polysulphonic  acids.  The  salts  of  the 
carboxylic  acids  and  the  other  phenol  dyes  are  less  suitable, 
while  the  nitro  dyes  are  the  least  suitable.  The  following 
members  of  the  acid  dyes  may  be  enumerated,  as  being  used 
for  the  purpose  of  forming  neutral  dyes :  orange  G,  acid  fuchsin, 
narcein  (a  freely  soluble  yellow  dye,  the  sodium  sulphanilate  of 
hydrazo  ;S-naphthol). 

If  a  solution  of  an  acid  dye,  such  as  orange  G,  be  dropped 
slowly  into  a  solution  of  methyl-green  a  coarse  precipitate  at 
first  takes  place,  which  is  completely  redissolved  on  the  addition 
of  more  orange  G  solution.     The  solution  is  prepared  so  that  the 

^  Kalle  &  Co.,  "  Badische  Anilin  und  Sodafabrik." 


THE   MORPHOLOGY  OF  TIIK   liLOOI)     43 

quantity  of  orange  G  i'k  jiisL  .sullicieiit  to  (IIkhoIvo  all  the 
preuiintutc.  A.  solution  ])i'(;])ai'('(l  in  this  manner  m  a  typical 
example  of  a  simple  neutnd  dye  Bolution.  The  example  given 
may  be  explained  chemically.  All  the  three  basic  groups  of 
the  methyl-green  in  this  mixture  are  combined  with  Uw,  acid  dye, 
so  that  a  triacid  compound  of  methyl-green  results. 

Simple  neutral  mixtures  which  have  one  component  in 
common  may  be  combined  with  one  another  without  further 
difficulty.  This  is  a  very  important  fact  for  triple  staining,  which 
has  proved  itself  of  utmost  value.  It  can  only  be  achieved 
by  mixing  together  two  simple  neutral  mixtures,  i.e.  twc 
mixtures  which  consist  of  two  components  each.  Chemical 
dissociation  does  not  take  place  under  these  conditions.  The 
important  group  of  staining  mixtures  containing  three  or  more 
dyes  are  obtained  in  this  way.  Theoretically,  there  are  two  main 
possibilities  for  such  combinations. 

1.  Dye  mixtures,  composed  of  one  acid  and  two  basic  dyes.  For 
example : — 

Orange-amethyst-nietliyl-green. 

JSTarcein-pyronin-inethyl-green. 

JSTarceiii-pyronin-methylene-blue. 

2.  Dye  mixtures,  composed  of  two  acid  dyes  and  one  basic 
dyes.     For  example  : — 

Orange  G-acid  fuchsin-methyl-green, 
Narcein-acid  fuchsin-methyl-green, 

and  also  the  corresponding  combinations  of  methylene-blue  and 
amethyst-violet.  The  first  of  these  mixtures  will  be  described 
in  greater  detail  later. 

The  importance  of  these  neutral  dye  solutions  depends  on  the 
fact  that  the  mixtures  colour  certain  structures  separately  which 
cannot  be  demonstrated  by  any  of  the  constituents  alone,  and 
which  are  therefore  called  neutrophik. 

Elements  which,  as  is  the  case  with  the  nucleiu  substances, 
possess  an  affinity  to  the  neutral  dyes  take  on  the  colour  of  the 


44  ANiEMIA 

basic  dyes  from  such  neutral  mixtures ;  while  the  acidophile 
elements  are  coloured  by  one  of  the  two  acid  dyes  of  the 
mixture.  Those  portions  of  the  tissues  which,  owing  to  the 
presence  of  definite  groups,  have  equal  affinity  to  the  acid  and 
basic  dyes,  attract  the  combined  neutral  dyes  to  themselves,  and 
are  therefore  stained  the  colour  of  the  mixture. 

Among  the  many  dye  combinations  which  microscopists, 
and  especially  hsematologists  have  tried,  the  mixtures  of 
methylene-blue  and  eosin  have  attracted  especial  attention. 
The  extraordinarily  beautiful  colour  contrast  between  these  two 
substances  which  is  not  likely  to  occur  frequently  is  to  a  large 
extent  responsible  for  this.  Not  only  have  the  details  of  a  large 
number  of  very  active  and  handy  methods  of  staining  with 
methylene-blue  and  eosin  in  two  stages  been  published,  and 
some  of  these  have  been  found  to  yield  good  results  in  practice, 
but  several  dozen  formulae  for  the  preparation  of  eosin-methylene- 
blue  mixtures  for  simultaneous  staining  have  also  been  described. 
It  is  quite  impossible  to  enumerate  all  these  mixtures  and 
methods  in  this  place,  and  it  is  presumed  that  it  will  be  found 
impossible  for  any  one  student  to  test  the  adequacy  of  each  of 
them  thoroughly.  Mention  will  therefore  only  be  made  of  the 
more  important  of  these,  and  of  those  which  have  proved  them- 
selves in  the  hands  of  the  authors  to  be  specially  efficient. 

Three  different  groups  of  these  mixtures  can  be  described. 
The  first  of  these  includes  those  formulae  which  have  aimed  at 
the  preparation  of  the  most  favourable  proportions  in  the 
mixture  of  the  two  dyes,  without  any  attention  having  been 
given  to  the  reciprocal  chemical  action  when  applied  to  the 
specimen  {e.g.  Chenzinsky's  solution);  the  second  and  third  are 
based  on  a  fact,  which  was  first  discovered  by  Eomanowsky,  that 
when  mixed  in  certain  proportions  these  two  dyes  in  solution 
form  a  new  chemical  substance.  This  possesses  in  its  nascent 
condition  specific  tinctorial  characteristics  which  are  not 
possessed  by  either  of  the  dyes  in  their  original  solutions.  In 
the    course  of  his   studies  of  the  malaria  parasite,  Eomanowsky 


THE  MORPHOLOGY  OF  THE   BEOOD     45 

was  able  to  obtain  exceptionally  good  chifjiiialin  slainin^r  in  this 
way,  and  less  regularly  good  neutrophile  granule  staining.  The 
discovery  of  the  "  red  in  inotliylone-ldue,"  i.e.  luetliylene-aznre, 
was  made  from  this  observation,  and  it  also  bid  to  tiie  lecogni- 
tion  of  a  stable  "  eosinate  "  of  methylene-bliu!  wbicli  dciiKJiiKirates 
the  neutrophile  elements  with  certainty. 

On  repeating  Eomanowsky's  method  of  cliromatiu  staining, 
other  observers  failed  to  obtain  regular  results.  Zicmann,  however, 
was  able  to  show  how  constant  results  could  be  obtained  after 
he  had  tried  all  the  commercial  preparations  of  methylene-blue, 
and  had  further  employed  borax  in  addition.  Nocht  was  the  first 
to  recognise  that  the  active  substance  in  this  staining  was  a  con- 
stituent of  commercial  methylene-blue,  which  he  termed  "  red  in 
methylene-blue."  It  was  left  to  L.  Michaelis,  however,  to  explain 
this  behaviour  chemically,  thereby  materially  advancing  the 
practical  solution  of  the  difificulty.  He  was  able  to  prove  that 
active  solutions  of  this  kind,  among  which  Unna's  polychromic 
methylene-blue  must  be  classified,  contain  methylene-azure  beside 
unaltered  methylene-blue.  This  substance  has  been  described 
by  Bernthsen,  who  regarded  it  as  a  sulphonic  dye ;  but  Kehrmann 
was  able  to  show  that  this  was  not  the  case,  but  that  it  was  a 
simple  dimethyl-thionin.  These  researches  have  rendered  it  easy 
to  prepare  the  active  dye  synthetically,  and  it  can  now  be 
obtained  in  a  pure  condition, — for  example,  from  the  "  Badische 
Anilin-  und  Sodafabrik."  The  most  advanced  use  of  this 
methylene-azure  staining  for  haematological  purposes  takes  the 
shape  of  "  Giemsa "  staining,  which  is  justly  much  in  vogue 
at  the  present  time  (see  below). 

A  number  of  investigators,  including  Eosin  and  Michaelis, 
have  contributed  towards  the  gaining  of  a  constant  eosinate  of 
methylene-blue,  on  which  the  htematologist  can  depend.  It  must, 
however,  be  mentioned  that  Jenner  described,  as  long  ago  as  in 
1899,  the  most  perfectly  active  product.  This  compound  was 
obtained  by  an  extremely  simple  method.  His  stain  yields  a  true 
panoptic  staining;  the  oxyphilic,  basophilic,  and  neutrophilic 
elements  of  the  normal  blood  are  characterised  sufficiently  sharply, 


46  ANEMIA 

and  all  the  most  important  pathological  changes  are  demonstrated 
by  its  means.  The  differentiation  of  the  neutrophile  from  the 
eosinophile  granules  may  not  be  quite  sharp  enough  for  an 
inexperienced  observer,  and  in  this  case  it  might  appear  that 
a  control  with  triacid  staining  would  be  advantageous. 

In  this  way  scientific  research  has  given  the  practitioner  a 
number  of  methods  which,  while  they  can  be  applied  with 
absolute  ease,  guarantee  the  results  with  precision.  These  methods 
have  been  arrived  at  as  the  result  of  endless  ingenuity  and  diligence, 
by  means  of  which  great  difficulties  have  been  overcome. 

For  practical  use,  apart  from  the  solution  of  iodine  and 
iodine  eosin  (which  will  be  described  on  pp.  52,  53),  the  following 
claim  attention : — 

1.  Haematoxylin  Solutions  with  Eosin  or  Orange  G — 


E.  Eosin  (cryst.) 

0*5  grm. 

Hsematoxylin 

2 

Alcohol  abs. 

Aquae  dest. 

Glycerini     . 

aa  100  grm. 

Acid  acetic  glac. 

.      10     „ 

Alum,  in  excess. 

The  solution  must  ripen  for  some  weeks.  Films  fixed  by  a 
short  exposure  to  heat,  or  in  absolute  alcohol,  stain  in  from  a 
half  to  two  hours.  The  haemoglobin  and  the  acidophile  granules 
stain  red,  while  the  nuclei  take  on  the  colour  of  the  hsematoxylin. 
The  stain  must  be  rinsed  off  very  carefully. 

2.  For  the  practical  employment  of  the  triacid  solution, 
it  is  especially  necessary  that  the  stains  employed  should  be 
chemically  pure.     Heidenhain  first  pointed  this  out.^ 

The  advantage  of  solutions  made  with  such  dyes  is 
particularly  well  exemplified  by  the  following  observation. 
Formerly   what   was   regarded    to    be    basophile    granules   were 

^  At  M.    Heidenliain's  request   the   "  Aktiengesellschaft  fiir  Anilinfarbstoffe," 
Berlin,  have  prepared  the  thi'ee  dyes  in  a  crystalline  condition. 


THE  MORPMOT.OCrY  OF  Tm^".  P»TX)OD     47 

frequently  seen  iji  white  blood  corpuscleH,  especially  in  tlio 
neighbourhood  of  the  nucleus.  Even  Huch  nu  experienced  observer 
as  Neusser  did  not  regard  these  granules  as  artifices.  They  were 
therefore  described  as  perinuclear  structures,  and  were  looked 
upon  as  being  true  cellular  elements.  Since  IJio  iiiLioduf.iiou  of 
pure  solutions  of  the  dyes,  these  so-called  basopliile  granules 
are  not  often  seen. 

Saturated  aqueous  solutions  of  the  three  dyes  are  first  made 
up  and  allowed  to  stand  until  clear.  They  are  then  mixed  in 
the  following  proportions  : — 

13-14  c.c.  of  orange  G  solution. 


6-7 

acid  fuchsin  solution. 

15 

distilled  water. 

15 

alcohol. 

12-5 

methyl-green  solution. 

10 

alcohol. 

10 

glycerine. 

These  ingredients  must  be  measured  out  in  the  same  measure 
glass  and  added  in  the  order  given.  After  the  methyl-green 
has  been  added  the  mixture  must  be  well  shaken  up.  The 
solution  is  ready  for  use  at  once,  and  will  keep  for  a  long  time. 
Staining  blood  films  with  triacid  need  only  be  preceded  by 
slight  fixation.  The  staining  itself  is  complete  within  five 
minutes. 

The  nuclei  then  appear  greenish  the  red  blood  corpuscles 
orange,  the  acidophile  granules  copper  colour,  and  the  neutro- 
phile  granules  violet.  Mast  cells  are  seen  as  peculiarly  pale, 
almost  colourless  cells,  with  pale  green  nuclear  substance. 
This  behaviour  is  spoken  of  as  negative  staining. 

It  will  thus  be  seen  that  triacid  staining  is,  technically 
spea'king,  quite  simple.  It  can  be  recommended  for  the  purposes 
of  gaining  a  general  conception  of  the  changes  in  a  given  specimen, 
and  must  be  regarded  as  being  indispensable  in  all  cases  in  which 
the  neutrophile  granules  have  to  be  studied. 

3.  Double  basic  Staining.— A  saturated  aqueous  solution 


48  ANiEMIA 

of  methyl-green  is  mixed  with  a  small  quantity  of  an  alcoholic 
solution  of  fuchsin. 

The  fixation  for  this  method  need  only  be  slight,  and  the 
staining  itself  is  complete  within  a  few  minutes.  The  nuclei 
appear  green,  the  red  corpuscles  red  and  the  protoplasm  of  the 
lymphocytes  take  on  the  colour  of  fuchsin.  This  method  is 
therefore  particularly  suitable  for  films  demonstrating  the 
changes  in  lymphatic  leuksemia. 

3a.  Pappenheim's  double  basic  staining  with  Pyronin 
Methyl-green. — The  directions,  according  to  Grawitz,  are  as 
follows.     The  two  following  solutions  are  prepared  : — 


1. 

Acid  carbol.  liq. 

0-25 

Aquse  dest. 

.     100 

Methyl-green  (pure)  . 

1-0 

2. 

Acid  carbol.  liq. 

0-25 

Aquse  dest. 

.     100-0 

Pyronin    . 

1-0 

15  parts  of  No.  1  are  mixed  with  35  parts  of  No.  2,  shaken 
up,  filtered,  and  allowed  to  stain  for  a  few  seconds.  The  fixation 
must  be  carried  out  with  heat.  The  solution  can  be  obtained 
ready  for  use  from  Griibler. 

4.  Eosin-methylene-blue  Mixtures. 

(a)  Chenzinsky's  solution. 

Concent,  watery  solution  of  methylene-blue    .  .  40  c.c. 

Half  per  cent,  solution  of  eosin  in  70  per  cent,  alcohol        20   „ 
Distilled  water     .         .         .         .         .         .         .         40   ,, 

The  solution  is  fairly  stable,  but  should  nevertheless  always 
be  filtered  before  use.  The  films  need  only  be  fixed  by  immersion 
in  alcohol  for  five  minutes.  The  staining  takes  from  six  to  twenty- 
four  hours,  and  is  carried  out  in  the  incubator  in  air-tight  block 
glass  pots. 

The  nuclei  and  the  mast  cell  granules  stain  an  intense  blue, 
malaria    plasmodia    stain    a   delicate   sky-blue,   the    red    blood 


THE  MORrnor.OGY  OF  TflP:  BI.OOD     49 

corpuscles  and  the  oosinophile  granulen  tuko  on  a  l)eautifu]  rod 
colour. 

This  solution  is  therefore  especially  suitable  for  the  study  of 
nuclear  structure  and  of  baso])hile  and  eosino])hile  f^ranulation. 
It  is  largely  used  for  ana'niic  and  lymphatic  Icukjcniic  blood. 

(&)  Von  JlluUem's  Successive  Staininfj. — This  method  has  been 
described  as  follows  by  Tlirk,  who  recommends  it  wariDly : — 

(a)  Pure  French  eosin,  |  per  cent,  in  70  per  cent,  alcoliol. 
(/;)  Methylene-blue  (B.  pat.)  I  per  cent,  in  water. 

1.  Fixation  for  three  minutes  in  methyl-alcohol. 

2.  The  films  are  transferred  directly  to  the  eosin  solution,  in 
which  they  stain  for  from  three  to  five  minutes. 

o.  They  are  then  rinsed  with  distilled  water  and  dried  between 
layers  of  blotting-paper. 

4.  They  are  then  placed  in  a  mixture  of  20  drops  of  the 
methylene-blue  solution  and  10  drops  of  the  eosin  solution  for 
from  a  half  to  at  most  one  minute.  The  proportions  for  this 
mixture  must  be  exactly  measured,  and  it  must  be  prepared 
fresh  for  each  staining. 

5.  Eapid  rinsing  with  distilled  water,  and  rapid  drying  between 
layers  of  blotting-paper.     Mounting  in  Canada  balsam 

(c)  Ten  c.c.  of  a  1  per  cent,  aqueous  solution  of  eosm,  8 
c.c.  of  methylal,  and  10  c.c.  of  a  saturated  aqueous  solution  of 
methylcnc-Uue  (medicinal)  are  mixed  together  and  used  at  once. 
The  staining  is  continued  for  one  or  at  most  two  minutes. 
The  staining  is  only  characteristic  if  the  films  have  been 
thoroughly  fixed  by  heat.  The  mast  cell  granulations  are 
coloured  pure  blue,  the  eosinophile  granules  red,  and  the  neutro- 
phile  granules  the  same  colour  as  the  mixture. 

(d)  Zicmanns  solution,  which  is  specially  adapted  for  malaria 
specimens  and  for  the  demonstration  of  lymph  cells. 

(a)  One. part  of  Hochst's  medical  methylene-blue  in  100  of 

distilled  water  and  2  to  4  parts  of  borax. 
ih)  Hochst's  eosin  A.  G.,  0"1  per  cent,  in  watery  solution. 

These  solutions  are  mixed  in  proportion  of  1:4.     The  film  is 
4 


50  ANAEMIA 

fixed  in  alcohol  and  is  stained  for  five  minutes.  A  metallic  skim 
which  forms  on  the  solution  should  be  removed  with  blotting 
paper,  to  prevent  it  from  coming  into  contact  with  the  film. 
The  film  is  then  rinsed  well  in  water,  immersed  several  times 
in  very  dilute  acetic  acid,  and  dried. 

(e)  In  the  next  place,  there  are  the  solutions  which  actually 
contain  "  eosinate  of  methylene-blue  "  ( Jenner,  May-Griinwald). 
Methyl-alcohol  is  employed  as  the  solvent,  so  that  the  fixation 
and  staining  take  place  at  the  same  time.  The  authors  re- 
commend the  hsematologist  to  obtain  either  the  eosinate  of 
methylene-blue  or  the  solution  ready  for  use  directly  from 
Griibler  of  Leipzig.  Burroughs,  Wellcome  &  Co.  put  up  the 
dye  in  small  so-called  "  soloids." 

A  half  to  1  per  cent,  solution  of  eosinate  of  methylene-blue  in 
methyl-alcohol  is  prepared,  and  the  films,  after  having  dried  in  the 
air,  but  without  any  previous  fixation,  are  immersed  in  the  solution 
for  about  five  minutes.  They  are  then  thoroughly  rinsed  off  with 
distilled  water,  during  which  process  they  are  decolorised  to  a  certain 
extent.    They  are  then  dried  and  mouated  in  Canada  balsam. 

When  stained  in  this  manner,  the  red  blood  corpuscles  and  the 
eosinophile  granules  appear  bright  red,  the  neutrophile  granules 
a  paler  red,  the  nuclei  and  the  mast  cell  granules  blue.  The 
cytoplasm  of  the  malaria  plasmodium  also  appears  pale  blue. 
Granulated  erythrocytes  can  be  demonstrated  well  by  this  method. 

(/)  Giemsa's  Staining. — The  preparation  of  methylene-azure 
solutions  is  still  very  complicated,  and  the  results  in  the  hands 
of  inexperienced  workers  are  uncertain.  It  is  therefore  wiser 
to  buy  Giemsa's  stain  solution  ready  for  use  from  Griibler  of 
Leipzig,  or  Klonne  &  Mliller  of  Berlin. 

The  fixation  is  performed  for  ten  to  twenty  minutes  in 
absolute  alcohol,  or  from  two  to  five  minutes  in  methyl-alcohol. 
For  staining  blood  films,  1  drop  of  Giemsa's  stain  is  added  to 
1   c.c.  of  distilled  water.^     This  is  allowed  to  act  for  from  ten 

^  The  translator  prefers  a  stronger  solution  of  Giemsa  for  blood  films  (2  drops 
per  c.c. )  to  act  for  three  to  six  minutes.  For  parasites  a  weaker  solution  is,  however, 
preferable. 


THE  MORPHOLOGY  OF  THE  15LOOD     51 

to  thirty  minut(3K.  Tfui  lilniH  uro  tlicii  liiiscd  willi  distillrid 
water  und  dried.  The  erythrocytciH  appear  ])Jile  red,  Llie  iiueh.'i 
of  the  inonoiiU(d(;ii.r  ond  ])olynucl(,'Jir'  loucocyteH  brij^Iit  refl  nnd 
violet  respectively,  parasites  and  tixi  plasma  of  the  lympho- 
cytes, blue,  neutrophile  granules  violet-rtid,  the  acidophils 
granules  a  brownish-red,  the  mast  cell  granules  a  mauve  colour, 
and  the  granulation  of  the  erythrocytes  blue  or  at  times  red. 

What  is  termed  "vital  staining"  requires  to  Ije  dealt  with 
separately.  This  term  is  a  very  unsuitable  one.  Ehrlich  first 
employed  it  for  the  staining  of  nerve  tissue  in  the  living 
animal,  and  in  this  connection  it  is  descriptive,  since  it 
actually  conveys  a  correct  meaning.  But  blood  leaves  off  being 
a  living  tissue  when  it  leaves  the  body,  and  begins  to  die  from 
the  moment  it  is  abstracted  from  the  vessels,  even  though 
under  favourable  conditions  it  is  possible  to  retain  the  form  of 
the  elements  unaltered  for  a  surprisingly  long  time.  It  must, 
however,  be  admitted  that  some  of  the  authors  who  employed 
the  term  {e.g.  Eosin  and  Bibergeil)  realised  that  it  was  not  a 
satisfactory  one.  It  would,  however,  have  been  wiser  if  they 
had  avoided  its  use  altogether  and  substituted  for  it  such  a 
term  as  "  post-vital "  or  "  prae-mortal "  staining.  But  whatever 
name  is  given  to  this  method,  the  author  is  of  opinion  that 
it  has  not  served  any  purpose  which  could  not  be  served  in  a 
much  more  convenient  manner  by  stained  dry  films.  It  is 
necessary  to  accept  with  the  utmost  caution  and  reserve  all 
that  is  claimed  as  new,  since  all  sorts  of  uncontrollable 
phenomena  may  be  produced  in  the  process  of  dyeing  when 
this  staining  is  employed.  It  must  even  awaken  suspicion,  if 
this  method  of  examination  reveals  appearances  which  cannot 
be  demonstrated  in  dry  stained  preparations.  These  remarks, 
of  course,  are  not  intended  to  apply  to  the  study  of  the 
phenomena  of  movement  of  the  blood,  which  cannot  be  achieved 
in  any  other  manner.  The  methods  of  vital  staining 
depend  either  on  the  solution  of  the  still  fluid  blood  in  the 
solution  of  the  dyes  (Arnold,  Pappenheim),  or  on  the  principle 


52  ANEMIA 

of  applying  the  blood  to  cover-glasses  on  which  an  alcoholic 
solution  of  the  dyes  has  been  previously  allowed  to  dry 
(Nakanischi,  Unna,  Eosin,  and  Bibergeil) ;  or,  lastly,  on  the 
principle  elaborated  by  Deetjens,  in  which  the  examination  is 
undertaken  in  a  medium  on  which  the  blood  can  be  preserved 
for  a  considerable  time,  and  in  which  the  dyes  have  been 
impregnated  (A.  Wolff). 

Two  further  important  methods  for  which  dry  blood  films  are 
utilised  without  any  previous  fixation  must  be  briefly  described 
before  this  subject  is  left  and  the  subject  of  the  histology  of 
the  blood  proper  is  entered  upon.  These  are :  (1)  The  detection 
of  glycogen  in  the  blood,  and  (2)  the  microscopical  demonstra- 
tion of  the  distribution  of  alkali  in  the  blood.  To  these  may 
be  added  (3)  the  so-called  diabetes  reaction. 

1.  Eecognition  of  Glycogen  in  the  Blood. 

This  can  be  carried  out  in  two  ways.  The  original  method 
consisted  in  placing  the  blood  in  a  drop  of  a  thick,  cleared 
solution  of  iodine  rubber  under  the  microscope,  in  accordance 
with  the  glycogen  test  devised  some  time  ago  by  Ehrlich. 
The  following  method,  however,  is  a  better  one.  The  blood  is 
placed  in  a  closed  vessel  containing  iodine  crystals.  Within  a 
few  minutes  it  takes  on  a  dark  brown  colour.  It  is  then 
embedded  in  a  saturated  solution  of  Isevulose,  which,  as  is  well 
known,  has  a  very  high  refraction  index.  It  is  necessary,  in  order 
to  preserve  such  specimens,  to  use  a  cover-glass  cement. 

When  either  of  these  methods  has  been  applied,  the  red 
corpuscles,  having  taken  on  the  iodine  stain,  become  prominent, 
without  showing  any  morphological  changes.  The  white  cells 
are  only  stained  to  a  slight  extent.  But  all  the  structures 
which  contain  glycogen,  be  they  in  the  white  blood  corpuscle,  be 
they  in  the  blood  platelets  or  extracellularly  in  the  debris,  appear 
very  markedly  characterised  by  a  beautiful  mahogany-brown 
colour.  The  second  modification  of  the  method  possesses  this 
advantage,  that  on  account  of  the  strikingly  refractive  action  of 


THE  MORPHOT.OCY  OF  TTTK   lU.OOD     53 

the  Isevulose  syrup  the  colour  can  be  seen  very  clearly,  while  with 
the  lodiKed  rubber  solution  small  quantities  of  glycogen  in  the 
cells  niiiy  be  obscured,  ])artly  by  tb(;  o])iUjue  iiatiii-c  of  tbo  rubber 
ii,ud  piirlly  by  the  colour  of  LIk!  solution  itself.  The  se.eond,  sharjjer 
method  may  therefore  be  recommended  for  more  extended  use  in 
the  examination  of  diabetes  cases  and  of  other  diseases.^ 

The  result  is  slightly  diri'erent  if  the  blood  smear  is  exposed 
to  iodine  vapour  while  still  moist  (Zollikofer).  When  treated 
in  this  manner  normal  white  blood  corpuscles  are  found  to  be 
impregnated  by  a  large  number  of  granules  stained  deep  brown, 
while  the  erythrocytes  are  stained  much  more  intensely  than  by 
the  dry  method. 


2.  The  Microscopical  Test  for  the  Distribution  of  Alkali  in  Blood. 

This  method  is  based  on  the  test  for  alkali  in  glass,  which 
Mylius  has  worked  out.  Iodide  of  eosin  is  a  red  compound 
which  is  very  soluble  in  water  but  insoluble  in  aether,  chloroform, 
and  toluol.  On  the  other  hand,  the  free  acid  of  the  dye,  as 
precipitated  from  the  salt  by  acidifying  the  solution,  is  very 
little  soluble  in  water,  but  is  readily  soluble  in  the  organic 
solvents.  On  shaking  it  up  thoroughly  in  an  aethereal  solvent 
the  precipitate  forms  a  yellow  solution.  If  such  a  solution  is 
applied  to  the  surface  of  glass,  on  which  alkali  has  been  de- 
posited as  a  result  of  the  decomposition  of  the  glass,  the  deposit 
takes  on  a  brilliant  red  coloration,  as  a  result  of  the  formation  of 
the  highly  coloured  salt  compound. 

In  applying  this  method  to  blood  it  is  of  course  necessary  to 
remove  any  deposition  of  alkaline  salt  from  the  vessels  or  cover- 
slips  employed  in  the  process  by  means  of  acid.  The  freshly 
prepared  dry  film  is  thrown  into  a  glass  vessel  containing  a 
solution  of  free  acid  iodide  of  eosin  in  chloroform,  or  chloroform 

^  This  method  can  be  warmly  recommended  also  for  the  detection  of  glycogen  in 
the  secretions,  e.g.  in  gonorrhoea]  pns,  which  always  shows  a  marked  glycogen 
reaction  of  the  cells  ;  the  same  reaction  is  further  found  iu  cells  derived  from 
tumours,  either  free  in  exudations  or  obtained  directly  from  the  gi-owths 
themselves. 


54  ANAEMIA 

and  toluol.  The  film  soon  becomes  dark  red  in  this  solution. 
It  is  then  rapidly  transferred  to  another  vessel  containing  pure 
chloroform,  and  the  chloroform  is  changed  once.  The  film  is  then 
mounted  while  still  wet  in  Canada  balsam.  The  mor photic 
elements  in  the  film  will  be  found  to  be  well  preserved.  The 
plasma  takes  on  a  distinctly  red  colour,  while  the  red  blood 
corpuscles  do  not  take  up  any  stain.  The  white  corpuscles  show 
a  red  staining  of  the  protoplasm,  in  which  the  nucleus,  being 
unstained,  appears  as  a  vacuole  (negative  nuclear  staining).  The 
debris  show  intense  red  coloration,  as  does  also  any  fibrin  which 
may  have  been  formed.  These  stainings  are  extremely  in- 
structive, and  frequently  demonstrate  minutiae  which  are  not 
visible  in  preparations  made  by  other  methods,  which  aim  more 
at  obtaining  elegant  specimens.  The  study  of  these  specimens  is 
of  the  utmost  value,  because  they  show  up  all  the  artificial  ap- 
pearances and  technical  mistakes  in  a  most  reliable  manner,  and 
thus  act  as  a  sort  of  control  to  technique.  The  scientific  value 
of  the  method  consists  in  giving  information  with  regard  to  the 
distribution  of  the  alkali  in  the  various  elements  of  the  blood. 
It  appears  that  free  alkali  which  reacts  to  iodide  of  eosin  is 
not  present  in  the  nuclei ;  these  structures  must  therefore  possess 
a  neutral  or  acid  reaction.  On  the  other  hand,  the  protoplasm 
of  the  leucocytes  is  always  alkaline,  and  it  is  found  that  the 
protoplasm  of  the  lymphocytes  contains  the  greatest  amount  of 
alkali.  It  is  also  necessary  to  call  attention  to  the  marked 
alkalinity  of  the  blood  platelets. 

3.  Bremer's  Diabetes  Reaction. 

Bremer  described  in  1894  a  peculiar  colour  reaction  of  the 
blood  of  diabetics.  At  first  he  employed  a  somewhat  com- 
plicated procedure,  but  later  described  the  following  method. 
A  fairly  thick  smear  of  the  blood  to  be  tested  is  made  on  a 
cover-slip,  and  this  is  fixed  at  125°  C.  and  stained  at  once  in  a 
2  per  cent,  solution  of  methylene-blue.  Diabetic  blood  when 
examined  under  the  microscope  is  found  to  be  stained  a  yellowish- 


THE  MOUrTIOLOCiV  OK  TIIK   lU.OOI) 


.'J  0 


green,  while    normia    blood    lakoH    on    lln;    colour    ol'    iho    .sl,:iiii 

employed. 

Williamson's  test  may  also  he  mc.td.ionod:  'ZU  o.f,.  oF  hlo..d 
(best  taken  by  means  of  the  i.ipotU-,  of  (Jower's  ha^mojrlohiiio- 
meter),  1  c.c.  of  a  1  in  GOUO  aqueous  solution  of  methylene-ljlue, 
and  40  c.c.  of  a  6  per  cent,  solution  of  caustic  potash  are  mixed 
in  a  test  tube  and  boiled  in  the  water  bath  for  three  or  four 
minutes.  Diabetic  blood  is  either  decolorised  or  tinted  faintly 
yellow  in  this  test,  while  normal  blood  solutions  retain  their 
colour.  The  test,  as  will  be  seen,  is  nothing  more  or  less  than 
a  simple  reduction  test. 

These  facts  have  been  confirmed  generally  by  a  number  of 
observers  (J.  Loewy,  le  Goff,  Hartwig,  Dannner,  and  others),  but 
at  the  same  time  it  was  found  that  the  reaction  is  not  specific 
for  diabetes,  but  occurs  at  times  in  other  conditions.  There  are 
considerable  differences  of  opinion  with  regard  to  the  interpreta- 
tion of  the  phenomenon,  and  at  present  it  is  not  possible  to 
consider  the  matter  settled.  There  is  no  doubt  that  the  re- 
action in  the  blood  of  diabetics  is  produced  by  the  presence  of 
grape  sugar.  Loewy  has  proved  that  in  Bremer's  test  the  blood 
corpuscles  cause  the  decolorisation,  while  in  Williamson's  test  it 

is  the  plasma. 

It  is  interesting  to  note  that  both  Williamson  and  Loewy 
have  still  obtained  the  reaction  in  diabetics,  after  the  glycosuria 
has  disappeared. 

According  to  Ehrlich,  these  phenomena  may  be  explained  on 
the  assumption  that  a  chemical  combination  between  the  glucose 
and  some  other  constituent  of  the  blood,  probably  the  haemo- 
globin, diminishes  the  power  of  taking  up  the  methylene-blue. 
This  view  is  supported  by  the  fact  that  normal  blood  which  has 
been  treated  with  grape  sugar  gives  a  Bremer's  reaction. 

There  is  no  doubt  that  this  reaction  occurs  in  other  diseases 
in  which  there  is  no  increase  of  the  sugar  of  the  blood. 


56  AA^iEMIA 

5.=— NORMAL  AND  PATHOLOGICAL  HISTOLOGY  OF 
THE  BLOOD. 

The  Red  Blood  Corpuscles. 

During  the  past  ten  years  new  views  have  been  put  forward 
with  regard  to  the  structure  of  the  red  blood  corpuscles,  which 
to  a  certain  extent  stand  at  variance  with  the  old  generally- 
accepted  ideas.  Special  mention  must  be  made  in  this  con- 
nection of  the  investigations  of  Weidenreich  on  the  shape  of  the 
erythrocytes.  As  a  result  of  extensive  comparative  anatomical 
studies  he  comes  to  the  conclusion  that  the  red  blood  corpuscles 
are  not  discs  provided  with  symmetrical  delled  concavities  on 
both  sides,  which  when  viewed  in  transverse  section  would  show 
the  so-called  dumb-bell  shape.  He  believes  that  they  have  the 
shape  of  a  bowl  or  bell  glass,  or,  as  he  very  expressively  explains 
it,  are  like  a  rubber  ball  from  which  some  of  the  air  has  escaped 
and  in  which  a  dent  has  been  made. 

These  views  with  regard  to  the  shape  of  the  red  cells  are  of 
purely  academic  interest,  and  do  not  convey  any  influence  on 
physiology  or  pathology.  The  various  hypotheses  with  regard 
to  the  structure  may  be  of  importance.  The  older  views  of 
oikoid  and  zooid  (Briicke),  of  discoplasm  (Ehrlich),  of  a  stroma 
in  the  meshes  of  which  the  haemoglobin  is  distributed  (Eollet, 
Hayem),  were  to  a  great  extent  based  on  the  demonstration  of  a 
framework  in  the  protoplasm  of  the  cells  by  Arnold  and  his 
pupils,  E.  Bloch,  Eosin,  Bibergeil,  and  others.  Weidenreich  and 
Grawitz,  however,  contend  that  the  protoplasm  of  the  erythro- 
cytes has  a  perfectly  homogeneous  structure.  The  latter  bases 
his  opinion  on  the  experiments  which  he  carried  out  with 
Grriineberg  with  ultra-violet  rays.  The  observers  named,  as  well 
as  Hamburger  and  others,  recognise  a  membrane  which  forms 
an  external  limit  of  the  blood  discs.  Weidenreich  believes  that 
this  membrane  possesses  basophile  characteristics,  and  that  it  plays 
a  part  in  the  development  of  punctation  and  of  blood  platelets. 

The  existence  of  a  membrane  has  been  accepted  by  Koppe, 


THE  MORPIIOLOCiY  OF  ^ITTE  IJLOOD     57 

and  by  Albrecht  and  Hedingor,  hh  the  j'ChuII  of  fuiUier  ui(;lliud8 
of  examination.  The  membrane  belongs  to  the  lipoid  subfitauces. 
It  contains  lecithin  and  cholenterine,  and  can  be  diHHolved  by 
definite  phyeical  and  chemical  mean.s.  Tliriso  views,  as  will  be 
shown  subsequently,  are  of  great  im])ortance  for  tlir;  dociiin*'  of 
the  pathogenesis  of  various  forms  of  an.'cmia. 

The  nucleoid  theory  opposes  the  doctrine  of  tlu;  liomogeneity 
of  the  red  blood  corpuscles.  'J'his  theory  assumes  the  remains 
of  nuclear  substance  in  the  interior  of  the  blood  discs,  which  it 
claims  to  demonstrate  by  special  forms  of  staining.  It  has  been 
supported  by  Pappenheini,  Arnold,  Hirschfeld,  Maximow,  and 
others,  and  has  received  remarkable  confirmation  by  Lowit's 
observations  with  fresh  blood  specimens  (quoted  by  Pappenheim), 
and  by  the  dark-field  illumination  studies  of  Pappenheim.  The 
latter  describes  the  nucleoid  substance  as  "  molecularly  motile," 
and  as  of  "  tenacious  fluid  consistence." 

The  views  with  regard  to  the  red  blood  corpuscles  which  are 
of  the  greatest  importance  for  clinical  medicine,  however,  are  not 
based  on  these  special  anatomical  and  physiological  examinations, 
but  have  been  formed  as  the  result  of  the  clinical  methods 
described  above,  and  especially  those  dealing  with  dry  films. 

A  technically  well  made  dry  film  shows  the  red  blood 
corpuscles  in  their  natural  size  and  shape,  and  the  cupping  or 
delling  can  be  distinctly  seen.  They  present  the  form  of 
isolated,  round,  homogeneous  structures  of  a  diameter  of  about  7*5 
to  8*5  jO;  (maximum  9-0  ^O/,  minimum  6"5 ///).  They  show^  the  most 
intense  staining  in  the  peripheral  zone,  and  the  least  in  the  dell 
or  centre.  The  stroma  does  not  take  up  any  of  the  stains 
mentioned  above.  The  dyes  only  affect  the  haemoglobin,  so  that 
an  experienced  observer  can  gain  some  idea  of  the  haemoglobin 
content  of  the  individual  cell  by  the  intensity  of  the  staining, 
which  is  much  more  reliable  than  the  natural  colour  of  the 
haemoglobin  in  fresh  unstained  preparations.  Blood  corpuscles 
which  are  poor  in  hasmoglobin  are  readily  recognised  by  their 
pale  staining,  and  especially  by  the  lightness  of  the  central  zone. 
When   this    is   very  marked   they   appear   as   structures   which 


58  "  ANEMIA 

Litteii  has  appropriately  called  "  pessary  "  forms,  on  account  of 
the  fact  that  only  the  periphery  stains  at  all.  The  slight  power  of 
staining  cannot  be  explained,  as  Grawitz  believes,  by  a  smaller 
affinity  of  the  haemoglobin  to  the  dye.  Qualitative  alterations 
of  the  hajmoglobin,  which  would  modify  its  behaviour  toward  the 
dye,  do  not  exist,  even  in  ansemic  blood.  The  fact  that  anaemic 
blood  stains  more  faintly  than  normal  blood  depends  entirely 
on  its  smaller  haemoglobin  content. 

A  diminution  of  the  haemoglobin  content  may  be  ascertained  in 
this  manner  in  all  the  anaemic  conditions,  and  especially  in  posb- 
haemorrhagic,  secondary,  and  chlorotic  anaemias.  In  contrast 
to  this,  however,  as  Laache  first  pointed  out,  there  is  an  increase 
in  the  amount  of  haemoglobin  in  a  large  number  of  erythrocytes 
in  pernicious  anaemia. 

In  order  to  form  a  correct  conception  of  pathological  changes 
in  blood,  it  is  necessary  to  bear  in  mind  that  the  individual  red 
blood  corpuscles  are  by  no  means  equal  even  in  normal  blood. 
Under  physiological  conditions  some  of  the  cells  are  constantly 
being  used  up  and  replaced  by  new  ones.  Each  drop  of  blood 
therefore  contains  erythrocytes  of  varying  age.  It  will  be  readily 
understood  that  damaging  influences,  provided  that  they  are 
not  too  great,  need  not  affect  all  the  red  blood  corpuscles 
equally.  The  least  resistant  of  the  elements,  i.e.  the  oldest 
cells,  will  be  destroyed  by  these  damaging  influences,  while  the 
more  robust  only  react  in  a  more  purposeful  manner  toward  the 
same  agencies. 

The  anaemic  composition  of  blood  as  such  undoubtedly 
constitutes  a  moderately  intense  stimulus  of  this  kind.  The 
action  may  be  studied  with  advantage  in  cases  of  acute  post- 
haemorrhagic  anaemia. 

Certain  characteristic  changes  are  observed  in  the  blood  discs 
in  all  anaemic  conditions. 

A.  Polychromatophilia. — This  term  is  employed  for  a 
condition,  which  was  first  described  by  Ehrlich,  in  which  the  red 
blood  corpuscles  show  a  modification  in  staining,  consisting  in 
taking  on  a  mixed  colour,  instead  of   a   pure   haemoglobin  tint, 


THE  MORPHC^T.OGY  OF  THE   1>,L()01)     o9 

as  in  iiormiil  blood.  For  example,  Uk;  vcA  l)lou<l  (^(npiiscUiK  in 
normal  blood  films  stained  by  tbc;  biemaloxylin-eosin  mixture  are 
stained  i)ure  rod.  Ti"  a  spoe.imen  of  tbe  blood  from  a  case  of 
chronic  anremia,  in  vvliicb  a,ll  ili<!  decrees  of  degeneration  are 
usually  present,  be  sLfiiiied  in  tb(!  Ha,m(!  in;uiii(;i-,  it  will  be  seen 
that  some  red  cells  have  a  faint  trace  of  violet.  Tbe  iilm  will 
contain  cells  which  have  taken  on  a  colour  which  at  best  may 
be  described  as  a  bluish  red,  and  others,  stained  a  fairly  intensely 
blue,  which  do  not  show  a  trace  of  the  red  tint ;  these  cells 
are  frequently  in  such  a  condition,  showinff  ragged  edges,  etc., 
that  they  may  be  regarded  as  dying  elements. 

Ehrlich  has  enunciated  the  theory,  that  this  peculiar  behaviour 
toward  the  stains  is  an  indication  of  the  gradual  dying  off  of  the 
red  blood  corpuscles,  and  especially  of  the  older  forms,  and  that 
this  change  leads  to  a  coagulation  necrosis  of  the  discofjlasm. 
The  latter,  as  is  always  the  case  with  coagulation  necrosis, 
charges  itself  with  the  albuminous  substances  of  the  blood,  and 
thereby  acquires  the  power  of  taking  up  the  nuclear  dyes.  At 
the  same  time,  the  discoplasm  loses  its  power  of  retaining  the 
hemoglobin  within  itself,  and  consequently  the  pigment  is  dis- 
charged into  the  fluid  portion  of  the  blood  in  quantities  propor- 
tional to  the  degree  of  the  changes.  Under  these  conditions 
the  red  discs  show  an  increasing  loss  of  specific  haemoglobin 
staining.  Ehrlich  speaks  of  this  behaviour  as  "anaemic  de- 
generation." 

These  views  have  been  challenged  by  various  observers — at 
first  by  Gabritschewski,  and  later  by  Askanazy,  Dunin,  etc. 
They  contended  that  the  polychromatophilic  discs  are  not  dying 
elements,  but  on  the  contrary  are  young  forms.  The  chief  fact 
on  which  this  opinion  was  based  was  that  in  certain  forms  of 
aneemia  the  precursors  of  the  nucleated  red  cells  are  frequently 
polychromatic,  as  far  as  their  protoplasm  is  concerned. 

In  view  of  the  great  theoretical  importance  of  this  matter 
it  is  thought  wise  to  briefly  recount  the  reasons  which  have  been 
put  forward  in  favour  of  the  degenerative  character  of  the 
changes. 


60     ;  ANiEMIA 

1.  The  appearance  of  those  erythrocytes  which  show  the 
highest  degree  of  polychromatophilia.  The  raggedness  of  the 
edges  lends  them  an  appearance  which  everyone  who  is 
accustomed  to  study  morphological  changes  would  accept  as  an 
indication  that  a  cell  is  undergoing  solution  and  is  markedly 
degenerate. 

2.  The  fact  that  these  changes  can  be  produced  to  a  marked 
degree  in  experiment  animals,  e.g.  by  inanition  under  conditions 
in  which  there  can  scarcely  be  any  question  of  new  formation  of 
red  blood  corpuscles ;  and  further  the  experiments  of  C.  S.  Engel, 
in  which  white  mice,  having  been  infected  with  hemorrhagic 
septicaemia,  show  numerous  polychromatic  erythrocytes. 

3.  The  clinical  experience,  that  these  staining  anomalies  may 
be  seen  in  a  large  number  of  cells  within  the  first  twenty-four 
hours  after  an  acute  haemorrhage  in  man.  According  to  the 
author's  extremely  careful  observations  in  this  connection,  involv- 
ing many  hundred  cases,  nucleated  red  blood  cells  are  not  found 
in  man  as  early  as  this.^ 

As  has  been  stated,  a  number  of  observers  opposed  the  view 
which  Ehrlich  at  first  put  forward  of  the  degenerative  nature 
of  the  phenomenon,  and  substituted  for  it  the  view  that  poly- 
chromatophilia is   a  peculiar   characteristic   of    young   elements. 

This  latter  view  has  been  supported  by  the  investigations  of 
Engel  on  the  development  of  the  red  blood  corpuscles.  He 
showed  that  nucleated  red  blood  corpuscles,  both  normoblasts  and 
megaloblasts,  frequently  reveal,  under  perfectly  physiological 
conditions,  even  a  markedly  polychromatic  protoplasm.  Naegeli 
has  recently  demonstrated  that  in  early  embryonal  stages  all  the 
erythrocytes  are  polychromatic.  Walker  was  able  to  show,  in 
some  comparative  studies,  that  in  certain  classes  of  animals  the 
circulating  blood  normally  contains  polychromatic  red  blood  discs, 
while  in  other  species  this  is  not  so.     It  therefore  appears  to  be 

^  Dunin  has  described  the  appearance  of  nucleated  red  blood  corpuscles  within 
the  first  twenty-four  hours  after  a  hremorrhage  in  man  as  a  normal  condition  which 
may  be  observed  regularly.  The  author,  however,  considers  that  this  view  is  not  in 
accordance  with  fact.  He  can  only  admit  that  single  instances  of  such  a  rarity 
may  be  met  with. 


THE  MORPHOJ.OGY   OF  THE  13r>OOI)     r>\ 

certain    that   ])olychroiriatophilia  riia,y   jiJho   be  a    HJgn   of    young 
forms. 

Thore  is  absolutely  no  reason  why  both  views  should  not  be 
accepted.  There  are  other  examples  in  histology,  and  especially 
in  hiEmatology,  of  young  and  dying  elements  having  similar 
characteristics ;  mononuclear  neutrophile  cells  must  be  regarded 
as  the  precursors  of  the  polynuclear  cells,  and  also  without  any 
doubt  as  a  degeneration  form  of  the  same  cells. 

^  The  genesis  of  this  phenomenon  is  of  course  different  for  the 
instance  when  it  represents  a  degeneration  form  to  that  when 
it  represents  an  early  developmental  stage.  In  the  former 
case  it  is  usually  dependent  on  acquired  pathological  charac- 
teristics of  the  circulating  blood,  produced  by  the  influence  of 
the  surrounding  blood  plasma  (see  above).  The  staining  peculi- 
arities may  also  be  produced,  according  to  Engel,  by  the  action  of 
bacteria  on  the  bone  marrow. 

With  regard  to  the  demonstration  of  polychromatophilia, 
suffice  it  to  mention  that  Tiirk  and  Naegeli  have  found  that 
methylene-blue  alone,  or  LofHer's  solution  of  methylene-blue,  are 
to  be  recommended  as  the  most  suitable  stains.  Very  beautiful 
results  can  be  obtained  with  Chenzinsky's  solution. 

JB.  The  Punctated  Erythrocytes. — In  various  conditions, 
punctate  and  at  times  coarse  deposits  are  met  with  in  the 
protoplasm  of  the  red  blood  corpuscles.  These  deposits  cannot  be 
seen  in  fresh  specimens,  but  may  be  demonstrated  in  dry  films 
by  means  of  almost  any  of  the  nuclear  stains.  At  times  these 
deposits  are  so  minute  and  so  closely  placed  that  the  whole 
cell  appears  to  be  stained  with  the  nuclear  dye.  For  example, 
when  stained  with  methylene-blue  the  cell  offers  an  appearance 
of  a  homogeneous  blue  structure.  In  other  cases  the  deposits  are 
coarse,  and  look  like  little  heaps  of  stain.  In  one  and  the  same 
cell  the  deposit  may  be  in  part  extremely  fine  and  in  part  very 
coarse.  Again,  it  may  be  distributed  equally  over  the  whole  cell, 
or  it  may  be  limited  to  a  part  of  it. 

Such  deposits  were  first  found  by  Ehrlich  in  1878,  and 
mentioned  in  a  dissertation,  compiled  under  the   supervision  of 


62  ANEMIA 

von  Noorden.  S.  Askanazy  described  these  elements  minutely 
in  a  case"  of  ansemia  in  1893,  and  in  1894  Schaumann  mentioned 
them  in  his  monograph.  A  communication  made  by  the  author, 
in  which  he  reported  that  he  had  found  these  elements  in  more 
than  twenty  cases  of  pernicious  ansemia  and  in  leukaemia,  appears 
to  have  awakened  general  interest  in  these  bodies.  The  author 
in  his  communication  suggested  the  term  of  punctate  erythrocytes 
for  this  condition  of  the  red  cells,  since  this  term  did  not 
presuppose  any  special  significance.  It  is  essential  to  avoid  the 
employment  of  any  term  which  could  suggest  the  slightest 
similarity  between  the  punctate  deposits  and  the  granules  of 
the  leucocytes.  Granules  are  structures  which  possess  definite 
functions  of  considerable  physiological  and  biological  importance, 
while  the  punctiform  deposits  of  the  erythrocytes  cannot  be 
said  to  serve  such  a  purpose.  For  this  reason  it  would  seem 
to  be  advisable  to  avoid  using  such  designations  as  "  basophile 
granulated  erythrocytes,"  which  might  be  easily  confused  with 
the  description  of  mast  cells  by  inexperienced  observers. 

An  extraordinarily  large  number  of  communications  followed 
the  publication  by  the  author,  dealing  with  further  characteristics 
of  these  bodies,  while  others  discussed  their  whole  significance 
(Klein,  Zenoni,  Lenoble,  Litten,  Borchardt,  E.  Bloch,  Engel, 
Bourret,  Sabrazes,  Strauss  and  Eohnstein,  A.  Plehn,  Grawitz 
and  his  pupils,  P.  Schmidt,  Naegeli  and  his  pupils,  S.  Askanazy 
and  others). 

These  communications  revealed  the  fact  that  punctate 
erythrocytes  may  be  found  in  all  forms  of  anaemia.  It  appears 
to  be  undoubted  that  this  form  of  cell  is  especially  marked  in 
those  anaemic  conditions  which  either  depend  on  toxic  causes 
or  in  which  these  factors  play  a  large  part  in  the  causation. 
Accordingly  they  are  found  almost  invariably  in  all  cases  of 
progressive  pernicious  anaemia,  carcinoma,  etc.  The  extremely 
frequent  occurrence  in  lead  poisoning  has  awakened  special 
interest,  after  Borchardt  first  called  attention  to  the  fact.  It 
has,  however,  been  proved  that  the  phenomenon  is  not  necessarily 
associated  with  toxic  processes,  since  it  has  been  seen  repeatedly 


THE  MORPirOLOGY  OF  THE  IUX)()I)     03 

in  cases  of  ])m-c  ]M).si-luemorrhagic  auajrnia,  ovom  if  Uu'h  in  not 
the  rule.  This  i.s  Tiot  only  true  for  hseniorrhageH  which  Uiko 
place  into  one  of  the  body  cavities,  as  Grawitz  believed,  under 
which  conditions  he  concludcul  tliat  a  toxic  action  was  produced 
by  the  abKor[)ti()n  of  the  l)li)()(l  wliicb  liiul  csciajjcd  IVoiii  the 
vessels,  but  applies  equally  to  those  forms  of  lia^rnftrrhage  in 
which  the  bleeding  takes  place  externally,  and  which  are  un- 
doubtedly cases  of  pure  acute  post-lucmorrhagic  aUcX-niia  (IJloch, 
Schmidt).  Mention  must  be  made  of  the  following  facts.  The 
punctate  erythrocytes  have  been  found  as  the  only  ascertainable 
blood  change  in  the  stage  of  complete  remission  in  prot^ressive 
pernicious  ana?mia  (Lazarus) ;  their  presence  may  form  the  first 
sign  of  lead  poisoning,  before  any  other  symptoms  have  made 
their  appearance ;  and  lastly,  according  to  Strauss  and  liohnstcin, 
they  have  been  observed  in  a  single  instance,  in  a  perfectly 
healthy  young  medical  man,  in  which  case  the  examination  was 
carried  out  with  extreme  care. 

Two  questions  have  been  thrown  up  by  all  the  authors  who 
have  busied  themselves  with  the  subject,  since  these  elements 
have  been  known  to  exist.  Firstly,  what  is  the  general  clinical 
significance  of  these  structures ;  and,  secondly,  what  is  their 
histological  explanation.  The  answers  to  these  tw^o  questions 
naturally  stand  in  close  association  to  one  another. 

No  one  will  dispute  that  the  punctate  elements  are  at  all 
events  in  part  derived  from  nuclear  structures.  This  becomes 
quite  evident  when  series  of  cells  are  examined,  such  as  those 
depicted  in  Part  II.  of  Ancemia,  Plate  2,  Fig.  5.  In  these  cells 
an  unbroken  series  of  fragments  from  the  largest  portions  of  the 
nucleus,  down  to  the  very  finest  punctiform  dust,  is  plainly 
visible.  But  this  by  no  means  proves  that  all  such  deposits  are 
derived  from  nuclei.  According  to  Grawitz,  a  certain  difference 
in  the  staining  speaks  against  the  view  that  the  deposits  are 
derivatives  of  the  nuclei.  This  objection,  however,  is  just  as  little 
convincing  as  it  would  be  if  it  were  assumed  that  basophilic 
staining  is  direct  evidence  of  a  nucleogenous  nature  ;  fragments 
of  nuclei,  as  Meyer  and  Speroui  have  appropriately  pointed  out, 


64  ANJEMIA 

need  not  behave  chemically  in  the  same  way  as  intact  nuclei. 
A  further  objection  consists  in  the  statement  that  this  punctate 
deposit  has  never  been  discovered  in  bone  marrow.  Pappenheim, 
however,  has  shown  that  it  is  quite  easy  to  demonstrate  it  in 
the  medulla  if  the  method  of  staining  be  but  slightly  modified. 
Schur  and  Loewy  and  Bloch  have  found  it  in  the  bone  medulla. 
Naegeli  was  able  to  demonstrate  the  presence  of  punctate 
deposits  in  bone  marrow,  even  in  cases  in  which  they  were 
absent  in  the  blood.  In  opposition  to  the  assumption  of  the 
nuclear  origin  of  the  punctate  deposits,  Grawitz  alleged 
that  he  had  found  innumerable  punctate  erythrocytes  in  the 
blood  of  many  patients,  without  having  come  across  a  single 
erythroblast.  Quite  apart  from  the  fact  that  this  could  not  be 
accepted  as  evidence  in  favour  of  Grawitz's  views,  Meyer  and 
Speroni  have  found,  more  especially  in  lead  poisoning,  that  when 
the  examination  is  undertaken  regularly,  erythroblasts  are  present 
in  every  case  which  shows  punctate  erythrocytes.  The  third 
argument  against  the  view  is  that  punctate  deposits  are  found 
in  erythroblasts  with  absolutely  intact  nuclei,  and  in  cells  which 
show  mitosis.  But  it  must  be  pointed  out  that  it  is  not  un- 
reasonable to  suppose  that  the  punctate  deposits  could  have 
been  derived  from  the  disintegration  of  a  second  nucleus,  or 
that  they  may  have  been  formed  during  the  process  of  division 
(Schmidt). 

Meyer  and  Speroni  have  recently  called  attention  to  a  highly 
important  fact.  In  animal  experiment,  punctiform  deposits  can 
only  be  produced  in  those  warm-blooded  animals  whose  red  blood 
corpuscles  normally  are  not  nucleated.  If  the  phenomenon 
depended  on  some  damage  to  the  protoplasm,  it  would  be  difficult 
to  understand  why  it  should  be  absent  in  those  warm-blooded 
animals  whose  red  blood  corpuscles  contain  nuclei.  The 
punctiform  deposits  only  occur  when  denucleisation  takes  place 
as  a  result  of  dissociation  of  nuclei  under  physiological  conditions. 

It  may  be  deduced  from  the  foregoing  that  some  of  the 
basophile  punctiform  deposits  undoubtedly  owe  their  origin  to 
the  nuclei,  while  it  cannot  be  proved    that  they   stand  in  any 


THE   MOKPITOLOCiY  OF  TJIK   ]MA)()\)     05 

causal  relation  to  ilio  protoplasm  of  the  coll.  Under  UicHe 
circumstances  it  seems  unnecessary  to  attempt  to  explain  one 
morphological  phenomenon  in  two  ways. 

Since  the  close  relationship  bctwe(;n  the  punctifoirn  deposits 
and  the  nuclei  suggests  that  this  ])he)n)menon  is  more  of  iiie 
nature  of  a  regenerative  than  a  degenerative  process,  it  is  interest- 
ing to  note  that  further  facts  have  been  In'ought  to  light  which 
support  this  view.  The  most  striking  evidence  has  been  obtained 
by  experiment.  Sabraz^s,  and  Naegeli  and  Lutoslawski,  whr^se 
work  fully  confirms  the  work  of  the  first  named,  have  shown 
that  punctate  erythrocytes  can  be  readily  produced  in  chronic 
lead  poisoning,  but  that  they  disappear  as  soon  as  the 
dose  of  poison  has  exceeded  a  certain  point.  This  result  can 
only  be  explained  on  the  assumption  that  the  punctate  ery- 
throcytes indicate  that  the  bone  medulla  reacts  actively,  while 
when  large  doses  are  employed  the  medulla  is  paralysed. 
Analogous  conditions  are  known  to  exist,  e.g.  in  experimental 
arsenical  poisoning  (Bettmann).  Schmidt  has  obtained  results 
which  tally  well  with  this  theory  in  his  experiments  with 
various  other  poisons. 

As  Naegeli  has  tritely  pointed  out,  the  appearance  of  this 
phenomenon  in  erythrocytes  showing  mitosis  speaks  in  favour  of  it 
being  a  regenerative  process.  It  would  be  absolutely  inconsistent 
to  suppose  that  a  degenerative  process  could  take  place  in  the 
same  cell  at  a  time  when  the  most  energetic  regenerative  process 
is  going  on.  Finally,  it  may  be  stated  that  the  fact  that 
basophilic  punctiform  deposits  have  been  found  in  embryonal 
blood,  that  is,  under  conditions  when  all  degenerative  processes 
may  be  regarded  as  excluded,  clinches  the  evidence  in  favour  of 
this  theory.  This  does  not  only  occur  in  the  embryonal  blood 
of  mice  in  which  it  was  first  observed  by  Engel,  but,  according 
to  recent  observation  of  Naegeli,  it  also  takes  place  in  the 
embryonal  blood  of  all  animals,  including  man. 

In  his  last  contribution  S.  Askanazy  has  admitted  ihat  these 
bodies  are  a  sisjn  of  regeneration.  But  in  contradiction  to  his 
earlier  views  he  now  considers  that  the  punctiform  deposits  are 
5 


G6  ANEMIA 

a  variation  of  polychromasia,  which  he  attributed  to  a  peculiar 
abnoriiiahty  of  the  plasma.  His  arguments  are  based  on  the 
alleged  condition,  which  has  been  disproved  in  the  preceding 
paragraph,  that  the  punctate  erythrocytes  have  never  been  found 
in  bone  marrow,  and  also  on  the  assumption  that  this  phenomenon 
appears  side  by  side  with  polychromasia.  This  is  certainly  not 
the  case  as  far  as  the  individual  erythrocytes  are  concerned.  A 
large  number  of  orthochromatic  erythrocytes  containing  punctiform 
deposits  are  met  with.  And  even  if  this  assumption  holds  good 
for  blood  as  a  whole,  it  must  be  pointed  out  that  this  is  not 
surprising,  since  the  phenomenon  of  polychromasia  is  observed  in 
nearly  every  case  of  anaemia. 

In  view  of  all  these  facts  and  theoretical  considerations  it 
appears  that,  although  this  may  be  to  some  extent  at  variance 
with  the  views  expressed  formerly  by  the  author,  the  following 
conclusions  are  justified.  The  punctiform  deposits  are  the  de- 
rivatives of  nuclear  substance,  and  the  process  must  be  regarded 
biologically  as  a  transformation  of  the  nuclear  substance, 
modified  by  pathological  conditions,  and  perhaps  as  an  altered  form 
of  denucleisation.  The  whole  phenomenon  therefore  bears  in  its 
clinical  significance  the  characters  of  a  pathological  regeneration. 

Schleip  found  in  a  case  of  progressive  pernicious  anaemia 
that  the  blood,  when  stained  by  Leishman's  and  Giemsa's  methods, 
contained  in  the  normal  or  polychromatophilic  erythrocytes, 
small  rings  or  much  twisted  loops  composed  of  extremely  delicate 
threads.  In  the  larger  erythrocytes  there  were  two  or  three 
rings,  and  at  times  rings  were  found  lying  free  in  the  blood 
plasma,  in  which  case  remnants  of  a  red  blood  corpuscle  could 
be  discerned  adhering  to  them.  Schleip  was  able  to  demon- 
strate these  changes  in  a  few  further  cases  of  progressive 
pernicious  ansemia,  in  severe  secondary  anaemia,  in  chronic  lead 
poisoning,  in  one  case  of  acute  leukaemia,  and  in  one  case  of 
pseudo-leukaemia.  He  regarded  these  structures  as  remains  of 
the  nuclei,  and  possibly  of  nuclear  membrane,  and  attributed 
the  condition  to  an  abnormally  increased  new  formation.     Schleip 


THE  MORPHOIXJGY  OF  THE  BI.OOD     G7 

has  stated  that  Ca})ot  dcsoribcd  the  Haiiie  condition  uh  early  as 
1903,  and  Gabriel  conHrnied  Schleip's  observation  in  a  single  ease 
of  progressive  pernicious  aniemia.  Naegeli  (private  (•oiiiiniiDi- 
eation)  has  found  very  numerous  ring  bodies  in  a  number  of 
cases  of  infantile  pseudo-leukajmic  anemia,  and  also  in  acute 
lymphatic  and  acute  myeloid  leukaemia,  as  well  as  in  progressive 
pernicious  anaemia  (see  Plate  III.). 

C. — A  third  change  which  is  found  in  the  red  blood  corpuscles 
in  ansemia  is  known  as  poikilocytosis  (Quincke).  This  term 
implies  a  change  in  the  microscopical  appearance  of  the  blood, 
which  is  characterised  by  the  presence  of  large,  small,  and  minute 
red  elements,  in  addition  to  a  greater  or  smaller  number  of 
normal  sized  red  blood  corpuscles,  "  anisocytosis "  (Strauss).  As 
Laache  first  pointed  out,  and  as  has  subsequently  been  confirmed 
by  other  hamatologists,  extremely  large  cells,  which  are  rich  in 
hsemoglobin,  are  found  in  Biermer's  anaemia.  In  all  other  severe 
and  moderately  severe  forms  of  anaemia  the  volume  and  hccmo- 
globin  content  of  the  red  blood  corpuscles  are,  as  a  rule,  diminished. 
This  apparent  contradiction  could  not  be  explained  by  Laache, 
who  first  called  attention  to  it,  but  has  been  satisfactorily 
accounted  for  by  the  results  of  Ehrlich's  observations  on  the 
nucleated  precursors  of  the  megaloeytes  and  normocytes  (see 
below). 

The  appearance  of  anaemic  blood  becomes  more  complicated  by 
the  fact  that  the  smaller  cells  do  not  retain  their  normal  shape, 
but  take  on  well-known  irregular  forms:  pear  shape,  balloon 
shape,  boat  shape,  and  dumb-bell  shape.  At  the  same  time,  the 
central  cupping  can  still  be  recognised  even  in  the  smallest  forms 
in  well-prepared  dry  films.  The  so-called  microcytes  form  an 
exception  to  this  rule.  These  are  small  globular  bodies,  which 
used  in  the  early  days  of  microscopical  haematology  to  be  regarded 
as  being  of  prognostic  importance  in  severe  forms  of  autemia.  It 
has,  however,  been  shown  that  these  bodies  are  merely  contraction 
forms  of  poikilocy tes ;  or,  in  other  words,  the  microcytes  stand 
in  the  same  relation  to  the  poikilocytes  as  the  crenated  forms 
stand   to  the  normal  erythrocytes.     Accordingly  microcytes  are 


68  ANEMIA 

but  rarely  seen  in  dry  films,  whereas  they  may  be  seen  in  fresh 
specimens  after  prolonged  examination. 

It  is  further  of  importance  to  know  that  in  fresh  blood  the 
poikilocytes  show  certain  movements ;  this  has  given  rise  to  wrong 
conceptions  in  many  instances.  They  were  regarded  as  the  causal 
organisms  of  malaria  in  the  early  days  of  hsematology ;  while  the 
larger  forms  were  looked  on,  at  a  later  date,  as  amoebae  and 
similar  organisms  by  Klebs  and  Perles.  Hayem  from  the  first 
described  these  forms  as  "  pseudo-parasites,"  and  warned  the 
observer  against  assuming  that  they  possessed  a  parasitic  char- 
acter. 

Formerly  the  origin  of  poikilocytes  was  the  subject  of  consider- 
able discussion,  but  it  is  now  generally  accepted  that  the  explana- 
tion which  Ehrlich  has  given  is  the  correct  one.  The  fact  that 
poikilocytosis  can  be  produced  in  any  specimen  of  blood  by  careful 
warming  has  led  to  the  deduction  that  these  forms  are  products 
of  a  fragmentation  of  the  red  blood  corpuscles  ("  schistocytes," 
Ehrlich).  This  view  is  further  supported  by  the  fact  that  even 
the  smallest  fragments  in  dry  films  show  a  definite  delling.  They 
contain  the  specific  protoplasm  of  the  blood  disc,  the  discoplasma, 
which  "  possesses  the  tendency  of  assuming  the  delled  form  in  the 
stage  of  quiescence." 

No  other  qualitative  alterations  of  the  protoplasm  of  the 
poikilocytes  can  be  demonstrated  even  by  staining.  They  may 
therefore  be  regarded  as  possessing  full  functions,  and  their 
presence  may  be  ascribed  to  a  purposeful  reaction  to  counteract 
the  diminution  in  the  number  of  blood  corpuscles.  The  respira- 
tory surface  is  considerably  increased  by  the  disintegration  of  a 
large  blood  corpuscle  into  a  number  of  homologous  smaller  cells. 

D. — A  fourth  change  in  the  morphological  condition  which 
is  seen  in  blood  in  the  severer  degrees  of  ansemia  is  the  presence 
of  nucleated  red  blood  corpuscles. 

While  the  question  of  the  origin  of  the  elements  of  the  blood 
cannot  be  followed  up  in  this  place  in  any  degree  of  minuteness, 
it  may  be  wise  to  describe  in  a  few  words  the  present  position 
of  the  doctrine  of  the  nucleated  red  blood  corpuscles. 


THE  MORPITOT.OCxY  OF  TTTE  BLOOD     09 

Nucleated  cxjUk  have  been  generally  accepted  as  tlu;  youiij,' 
forms  of  the  normal  red  blood  corpnHcle«  ever  since  Neumann 
and  Bizznzero  publisluul  their  Htandard  works  (October  anrl 
November  186(S).  Jlayem's  Uicory,  on  tlie  other  hand,  according 
to  which  the  blood  platelets  arc  tlic  origin  oi"  tlu;  (nythrocytes,  may 
be  regarded  as  having  been  disputed  by  evoryoii.i  save  this  author 
and  his  pupils. 

Ehrlich  called  attention  to  the  clinical  significance  of  the 
nucleated  red  blood  corpuscles  in  1880,  by  pointing  out  that 
cells  of  normal  size — normoblasts — occurred  in  the  so-called 
secondary  antemias  and  in  leukaemia,  and  very  large  elements — 
megaloblasts,  gigantoblasts  —  occurred  in  Biermer's  ansemia. 
Ehrlich  at  the  same  time  emphasised  the  fact  that  the  megalo- 
blasts play  an  important  part  in  the  embryonal  formation  of  blood. 
In  1883,  Hayem  sought  to  classify  the  nucleated  red  corpuscles 
into — (1)  The  "  globules  nuclees  geantes,"  which  were  only  to  be 
found  in  the  embryonal  condition ;  and  (2)  the  "  globules  nuclees 
de  taille  moyenne,"  which  are  j)resent  in  the  late  stages  of  em- 
bryonal life  and  always  in  adults.  W.  H.  Howell  (1890)  recog- 
nised two  kinds  of  erythrocytes  in  cat  embryos :  (1)  A  very  large 
blood  cell,  similar  to  the  blood  cells  of  reptiles  and  amphibia 
("  ancestor  corpuscles  ") ;  and  (2)  a  blood  cell  of  the  usual  size  of 
mammalian  blood  corpuscles. 

Three  forms  of  nucleated  red  blood  corpuscles  may  be  dis- 
tinguished by  the  following  characteristics : — 

1.  Normoblasts. — These  are  red  blood  corpuscles  of  the 
size  of  the  ordinary  non-nucleated  discs ;  the  protoplasm  shows, 
as  a  rule,  pure  haemoglobin  coloration ;  they  have  one  nucleus  as  a 
rule  and  at  times  there  are  from  two  to  four.  The  nucleus  is 
pycnotic,  has  well-defined  edges,  and  apparently  no  differentiated 
structure.  It  is  usually  concentrically  situated,  and  occupies  the 
greater  part  of  the  cell.  It  is  characterised  by  the  capability  of 
taking  on  a  more  intense  degree  of  staining  with  the  nuclear  dyes 
than  do  the  nuclei  of  the  leucocytes,  or  indeed  of  all  other  cells. 
This  property  is  so  characteristic  that,  even  when  free  nuclei  are 
met  with  around  which  no  or  exceedingly  little  haemoglobin  can  be 


70  ANiEMIA 

distinguished,  as  is  the  case  at  times  in  anaemias,  and  especially  in 
leukaemia,  they  can  be  readily  recognised  as  normoblast  nuclei. 

2.  Megaloblasts. — These  cells  are  from  two  to  four  times 
the  size  of  normal  red  blood  corpuscles.  Their  haemoglobin 
occupies  by  far  the  greater  part  of  the  cell,  and  frequently  shows 
more  or  less  marked  degrees  of  anaemic  degeneration.  The  nucleus 
is  larger  than  that  of  the  normoblasts,  but  does  not  occupy  so 
large  a  portion  of  the  cell  as  the  latter  does.  It  is  frequently 
ill  defined,  and  has  a  rounded  shape.  The  nuclei  of  the  megalo- 
blasts may  be  distinguished  from  those  of  the  normoblasts  by 
their  finely  differentiated  structure  and  by  their  small  capability 
of  taking  up  nuclear  stains,  which  may  be  so  limited  that  an 
inexperienced  observer  may  have  difficulty  in  recognising  that  the 
cells  have  a  nucleus  at  all. 

At  times  cells  corresponding  to  the  form  described  above,  but 
of  a  considerably  larger  size,  are  met  with.  These  cells  are 
termed  gigantoblasts,  but  are  regarded  as  being  of  the  same  type 
as  megaloblasts. 

3.  Microblasts. — These  forms  occur  at  times,  as,  for  example, 
in  traumatic  anaemias,  but  must  be  regarded  as  extremely  rare 
cells.  They  have  not  attracted  the  especial  attention  of  the 
haematologist  up  to  the  present. 

Practically  every  haematologist  of  repute  has  followed  Ehrlich's 
propositions  in  the  morphological  classification  of  the  nucleated 
red  blood  corpuscles.  Marked  differences  of  opinion  have  only 
been  expressed  with  regard  to  the  significance  of  the  two  chief 
forms.  There  is  no  doubt  that  this  difference  of  opinion  depends 
in  part  on  the  fact  that  some  of  these  investigators,  in  using  the 
classification  introduced  by  Ehrlich,  have  not  adhered  strictly  to 
his  definitions.  It  is  not  unreasonable  to  expect  that  when  a 
name  has  been  suggested  for  a  definite  matter,  this  name  should 
not  be  employed  to  signify  some  other  phenomenon  or  structure. 
This  claim  has  not  been  respected  in  modern  haematology.  When 
an  investigator  considers  that  the  suggested  term  is  unsuitable  in 
any  respect,  he  can  propose  a  new,  better  term,  but  he  should  not 


THE  MOlMMIOr.OCiY  OF    IIIK   liLOOI)     71 

create  confusion  by  ji,  rnisc.  us(;  of  Uk;  oi'igiiial  one.  iMariy  of 
the  disagr(;onicntB  with  ro<,rar(l  to  J^^hrlicli's  doctrine  conceniing 
the  normoblasts  and  nicgaloblasts  would  not  have  occurred  if  all 
the  authors  had  respected  this  regulation.  In  order  to  gain  a 
perfectly  clear  conception  of  the  physiological  and  pathological 
import  of  the  crythroblasts,  it  is  absolutely  necessary  to  consider, 
in  the  first  place,  only  typical  examples  of  both  forms.  There 
are,  as  would  be  expected,  a  large  number  of  cells  which  cannot 
be  classified  either  as  normoblasts  or  as  megaloblasts,  on  account 
of  the  fact  that  some  of  the  characteristics  which  Ehrlich  des- 
cribed for  these  cells  are  wanting.  It  would,  however,  be  purpose- 
less and  would  not  contribute  towards  success  if  atypical  inter- 
mediate forms  were  utilised  for  the  purpose  of  gaining  a  clear 
insight  into  the  significance  of  the  definite  and  typical  forms 
which  can  be  accepted  as  standards. 

Turning  first  to  the  physiological  occurrence  of  normoblasts 
and  megaloblasts,  everyone  is  agreed  that  only  the  latter  variety 
is  met  with  in  the  earlier  embryonal  stages.  This  variety  is 
gradually  replaced  by  the  former,  so  that  the  blood  of  the  fully 
developed  foetus  does  not  contain  any  megaloblasts,  although 
the  bone  marrow  still  does  so.  The  same  remark  applies  at 
times  to  the  first  two  years  of  life.  No  one  has  ever  claimed 
to  have  found  megaloblasts  in  the  blood  of  healthy  adults.  In 
spite  of  very  extensive  observations,  neither  Ehrlich,  Bloch,  nor 
the  author  have  ever  found  megaloblasts  in  the  bone  marrow 
of  adults;  while  Dominici,  Naegeli,  Grawitz,  Engel,  and  others 
claim  to  have  seen  megaloblasts  as  rare,  and  even  very  rare, 
constituents  of  normal  bone  marrow.  These  exceptional  finds, 
however,  suffice  to  impel  Grawitz  to  regard  the  megaloblasts 
as  "a  type  of  normal  blood  formation."  He  seeks  to  establish 
this  view  by  setting  up  a  hypothesis  of  a  development  of 
megaloblasts  as  a  result  of  an  increased  water  content  of  the 
blood.  While  this  assumption  appears  to  be  untenable  in  view 
of  the  function  of  the  megaloblasts  in  the  embryonal  blood 
formation,  and  of  the  high  hemoglobin  content  of  the  cells, 
some  recent   experiments   of   Georgopulos   have   deprived  it   of 


72  ANiEMIA 

all  foundation.  This  observer  showed  that  in  hydremic  con- 
ditions ■  absolutely  no  swelling  of  the  erythrocytes  takes  place, 
and  he  was  even  able  to  demonstrate  that  on  the  appearance 
of  disturbance  of  compensation  of  the  heart  in  persons  suffering 
from  renal  affections,  and  from  the  consequent  increase  in  the 
concentration  of  the  blood,  the  diameter  of  the  erythrocytes  is 
increased  on  the  average. 

All  other  hsematologists  are  agreed  that  the  normoblasts  of 
the  bone  marrow  alone  are  the  physiological  precursors  of  normal 
red  blood  corpuscles.  It  is  at  present  impossible  to  prophesy 
what  explanation  will  be  found  for  the  contradictory  observations 
of  Ehrlich  on  the  one  hand,  who  failed  to  find  megaloblasts  in 
the  marrow,  and  Dominici  and  others  who  found  them  on  a  few 
occasions. 

It  is  necessary  to  consider  the  fate  of  the  nuclei  of  the 
erythroblasts  separately,  in  spite  of  the  fact  that  this  landmark 
is  no  longer  regarded  as  important  as  it  formerly  was  for 
the  differentiation  of  the  two  forms  of  cells.  For  a  long  time 
two  views  with  regard  to  the  transformation  of  the  nucleated 
erythroblasts  into  the  non-nucleated  erythrocytes  were  opposed 
to  one  another.  Eindfleisch,  who  was  the  chief  exponent  of  the 
one  view,  taught  that  the  nucleus  of  the  erythroblast  issued 
from  the  cell,  leaving  it  in  the  form  of  an  erythrocyte,  and 
that  the  nucleus  itself  took  up,  by  means  of  a  trace  of  proto- 
plasm, which  still  adhered  to  it,  fresh  substances  out  of  the 
plasma,  imbibed  haemoglobin,  and  thus  shaped  itself  into  an 
erythroblast  again.  The  other  doctrine,  which  was  directly 
irreconcilable  to  the  former,  assumed  that  the  erythroblasts  were 
transformed  into  non-nucleated  discs  by  the  disintegration  of 
the  nucleus  within  itself  ("  karyorrhexis,  karyolysis  ").  KoUiker 
and  E.  Neumann  may  be  particularly  mentioned  as  having 
championed  this  view,  and  as  having  regarded  it  as  the  only 
way  in  which  the  erythrocytes  are  formed. 

Eindfleisch  arrived  at  his  theory  by  direct  observation  of 
the  phenomenon,  which  he  described.  He  saw  this  take  place 
in  the  blood  of  guinea-pig  embryos  and  in  teased  bone  marrow 


THE  MORPriOT.OCiY  OF  TTTE  lU.OOD     73 

preparations,  both  of  whicli   lia,(l  l.(!(^n  lic.;itr'<l  wiU,  i-liyHiological 

salt  solution. 

E.  Neuiiiiiiin  slatcM  llmi  liiii'ltlciscli's  (Inclriiic  \v;is  uiit(;nablo, 
l)ecause  the  process  wliicli  Mk;  l:iiL«T  Ii;m1  w.-i.tcli.-l  was  simply 
the  result  of  a  losioii  of  ihc.  Ijlood  pro(luf(Ml  by  the  salt  solution 
and  by  the  teasing.  When  a  niothod  of  preparing  the  specimena 
was  selected,  by  means  of  which  all  chemical  and  mechanical 
changes  in  the  blood  could  be  avoided,  the  issuing  of  the  nucleus 
did  not  take  place. 

Kolliker's  and  Neumann's  view,  that  the  nucleus  gradually 
disintegrates  in  the  interior  of  the  cell,  is  not  based  on  obser- 
vation of  the  process,  but  is  based  on  the  fact  that  in  suitable 
specimens,  e.g.   of  foetal   bone  marrow,  blood  of    the  liver,  and 
also    leukemic    blood,    the     transition    from    erythroblasts     to 
erythrocytes   can   be   demonstrated   in    every    stage   of   nuclear 
metamorphosis ;  von  Eecklinghausen  claims  to  have  observed  the 
solution  of  the  nucleus  within  the  cell  itself   in  rabbit's  blood, 
which    was   kept   alive   in   the    moist    chamber.     Pappenheim's 
criticism,  that  the  last-named   observer   had  watched  a  process 
analogous    to    that   described   by   Maragliano  and   Castellino   as 
artificial  blood  necrobiosis,  should  be  mentioned  in  this  connection. 
Similar  differences  of  opinion  are  displayed  with  regard  to 
the  significance  of   the   "free"   nuclei,    which   may   be   seen  in 
many   specimens.     Kolliker  taught  that  these  nuclei  were   not 
absolutely  free  from  protoplasm,  but  that  a  narrow  investment 
of  protoplasm  could  always  be  made  out.     Eindfleisch  regarded 
them  as  nuclei  which   have   been  cast   out   of,   or   have   issued 
from,   the    erythroblasts;    while    Neumann   described   them    as 
young  forms  of  erythroblasts. 

The  investigations  of  the  last  ten  years  have  failed  to  reconcile 
the  champions  of  these  doctrines.  It  is  unnecessary  to  discuss 
the  methods  and  stages  of  examination  which  the  various  authors 
have  followed.  Suffice  it  to  mention  that  the  names  of  E. 
Albrecht,  Howell,  INI.  Heidenhain,  v.  d.  Stricht,  and  Junger  have 
appeared  in  support  of  Eindfleisch :  while  IMassloff  and  Naegeli 
have  recently  taken  up  the  cudgels  for  Neumann  and  Kolliker. 


74  ANiEMTA 

Ehrlich  first  attempted  to  bridge  over  the  gap  placed  between 
the  two  conflicting  views  of  Eindfleisch  and  Neumann.  He 
taught  that  both  forms  of  origin  occurred.  It  was  quite  easy 
to  demonstrate  in  blood  films,  which  contained  plenty  normoblasts, 
e.g.  from  cases  of  "  blood  crises  "  or  leukaemia,  complete  series 
illustrating  how  the  nuclei  of  erythroblasts  leave  the  cells  and 
then  appear  as  so-called  "free  nuclei."  It  must  be  specially 
pointed  out  that  these  appearances  may  be  found  in  specimens 
in  the  preparation  of  which  absolutely  no  pressure  has  been 
exercised.  On  the  other  hand,  no  matter  how  many  normo- 
blasts a  specimen  of  blood  may  contain,  it  has  never  been 
possible  to  demonstrate  Neumann's  metamorphosis  of  the 
nucleus.  The  reverse  holds  good  for  megaloblasts.  Among 
these  cells,  but  few  examples  are  met  with  which  do  not 
show  distinct  traces  of  dissociation  of  the  nucleus  and  solution 
of  the  same.  In  a  good  specimen  of  the  blood  in  Biermer's 
anaemia,  which  does  not  contain  too  few  megaloblasts,  an 
unbroken  series  of  megaloblasts  with  intact  nucleus,  through 
all  the  stages  of  karyorrhexis  and  karyolysis,  right  down  to 
megalocytes,  in  full  accord  with  Neumann's  description,  may 
be  followed. 

M.  B.  Schmidt,  Arnold,  Helly,  Tiirk,  Grawitz,  Engel  and 
Bloch,  like  Ehrlich,  have  accepted  the  intermediate  position,  by 
acknowledging  the  occurrence  of  both  forms  of  denucleisation. 
These  authors,  however,  differ  from  Ehrlich  with  regard  to  the 
differential  separation  of  both  kinds  of  cells  by  the  way  in  which 
the  nucleus  is  got  rid  of.  Ehrlich  ascribed  the  casting  out  of 
the  nuclei  to  the  normoblasts  and  the  solution  to  the  megalo- 
blasts. 

Clinical  differences. — Normoblasts  are  found  almost  regularly 
in  every  form  of  severe  anaemia  which  is  caused  by  trauma, 
inanition,  or  an  extraneous  form  of  organic  disease.  As  a  rule 
they  are  sparse  \  after  a  prolonged  search  only  one  such  cell  may 
be  found.  At  times,  however,  one  or  more  normoblasts  are  found 
in  each  field.  This  is  most  frequent  in  acute  cases,  but  may  also 
occur  in  chronic  anaemias,  and  even  in  cachectic  conditions. 


THE  MORPHOT.OCV  OF  ^rilE  lUX)OI)     75 

Von  Noorden  wus  tho  IIibL  to  (loscrihc  a  c-jisc  in  wliicli  u  laigo 
number  of  normoblasts  occurred  t(!iii|)oi;uily  in  the  circulating 
blood  in  a  case  of  hasmorrliiigic  ana^inia;  the  microscopical 
appearance  of  the  blood,  in  which  there  was,  at  the  same  time, 
a  marked  hyperleucocytosis,  simulated  that  of  iriyeloid  ]euka.'n)ia. 
As  the  number  of  blood  cells  was  found  in  this  condition  to  be 
close  on  double  tliat  of  normal  blood,  von  Noorden  called  this 
blood  condition  "blood  crisis." 

The  following  procedure  is  recommended  for  the  exact 
recognition  of  the  blood  crises : — 

1.  Determination  of  the  number  of  red  cells. 

2.  Determination  of  the  proportion  of  white  corpuscles  to  red 
corpuscles. 

3.  Determination  of  the  proportion  of  nucleated  red  to  white 
corpuscles  in  the  dry  film.  The  author  recommends  the  use  of  the 
quadratic  ocular  for  this  purpose  (see  p.  32). 

For  example,  if  in  a  case  of  ansemia,  3^  millions  red  cells  are 
counted,  and  it  is  found  that  the  proportion  of  white  to  red  is  1  :  100, 
and  of  nucleated  red  to  white  1  :  10,  there  will  he  3500  nucleated  red 
corpuscles  in  each  cubic  mm.  i.e.,  there  will  be  1  nucleated  to  1000 
ordinary  red  blood  corpuscles. 

On  the  other  hand,  megaloblasts  are  never  found  in  the  blood 
in  traumatic  anaemia.  They  will  likewise  be  looked  for  in  vain 
in  nearly  every  case  of  chronic  anaemia  of  a  severe  type,  such 
as  that  produced  by  syphilis,  cancer  of  the  stomach,  and  the  like, 
but  they  will  be  found  at  times  in  leukemic  blood.  The  behaviour 
of  the  bone  marrow  in  various  diseases  has  been  studied  from 
this  point  of  view  by  a  number  of  observers.  Schur  and  Loewy 
found  megaloblasts  in  small  numbers  in  two  cases  of  carcinoma, 
and  in  one  of  phosphorus  poisoning,  and  Wolownik  found  the 
same  in  a  few  cases  of  carcinoma  and  one  of  chronic  nephritis. 
On  the  other  hand,  some  apparently  much  milder  conditions,  in 
which  the  diagnosis  of  an  essential  progressive  antemia  is  rendered 
probable  by  the  anamnesis,  aetiology,  and  general  objective 
condition,  are  almost  always  characterised  by  the  appearance  of 


7Q  ANEMIA 

megaloblasts  in  the  blood.  But  even  in  the  advanced  stages  of 
the  disease  these  cells  are  not  plentiful,  and  a  tedious  examination 
of  one  or  more  specimens  is  frequently  required  to  find  them. 
From  this  fact  a  rule  has  been  formulated  that  the  examination 
of  the  blood  in  a  case  of  severe  ansemia  must  not  be  regarded  as 
complete  until  at  least  three  or  four  specimens  have  been  care- 
fully studied  under  the  oil-immersion  for  megaloblasts. 

This  clinical  difference  between  the  two  forms  of  hsemato- 
blasts  only  admits  of  one  deduction,  which  does  not  touch  upon 
the  much  disputed  question  whether  the  megaloblasts  or  normo- 
blasts may  be  transformed  into  one  another.  Normoblasts  are 
found  in  all  those  cases  of  anaemia  in  which  the  new  formation  of 
blood  takes  place  under  normal  conditions  only  in  an  increased 
degree,  and  in  a  more  energetic  manner.  Nearly  all  the 
anaemias,  of  which  the  cause  is  known :  acute  haemorrhage, 
chronic  haemorrhage,  anaemia  due  to  inanition,  cachexia,  blood 
poisons,  hsemoglobinaemia,  etc., — in  short,  all  those  conditions 
which  are  classed  together  under  the  name  of  secondary  symp- 
tomatic anaemias,  may  show  this  increase  of  the  normal  blood 
formation.  In  opposition  to  this,  megaloblasts,  which  represent 
the  embryonal  type,  are  found  in  those  conditions  which 
Biermer  distinguished  under  the  name  of  essential  pernicious 
anaemias,  on  account  of  their  clinical  characteristics.  Laache 
has  demonstrated  how  important  this  form  of  blood  formation  is 
in  pernicious  anaemia,  by  pointing  out  that  in  all  such  cases 
megalocytes  are  present,  and  in  many  cases  in  such  numbers 
that  they  form  the  majority  of  the  corpuscles.  While  the  red 
blood  corpuscles  in  the  simple  forms  of  anaemia  tend  to  produce 
smaller  forms,  the  opposite  holds  good  solely  and  only  in  the 
pernicious  form.  This  constant  difference  cannot  be  explained 
as  an  accidental  find,  but  must  be  recognised  as  a  regular  occur- 
rence. In  pernicious  anaemia  extremely  large  blood  corpuscles 
are  formed.  This  logical  sequence  has  been  confirmed  to  the 
full  by  Ehrlich's  demonstration  of  megaloblasts.  All  attempts 
to  smooth  over  the  differences  between  megaloblasts  and  normo- 
blasts, or  to  deny  that  such  differences  exist,  must  fail  before  the 


THE  MORPHOr.OGY  OF  THE   lU^OOD     11 

clinical  fact  that  the  blood  of  poniicioiiB  aiuuinia  is  a  incgalocytic 
blood. 

The  appearance  of  niegaloblast.s  and  nicgalocytes  m  a  proof 
that  the  regeneration  of  the  blood  in  the  bone  marrow  does  not 
take  place  normally,  but  that  it  follovv.s  a  typt;  more  cloHcly 
related  to  the  embryonal  type.  Extreme  cases,  like  the  one  reported 
by  Kindileisch,  in  which  the  whole  bone  marrow  was  found  to 
be  full  of  megaloblasts,  are  necessarily  rare ;  bat  the  pernicious 
character  may  be  regarded  as  sufficiently  proved,  "if  a  consider- 
able portion  of  the  bone  marrow,  and  not  necessarily  the  whole 
of  it,  reveals  megaloblastic  degeneration."^ 

It  may  be  said  that  the  megaloblastic  transformation  is  a 
highly  purposeless  process,  for  the  following  reasons:  (1) 
Because  the  formation  of  red  blood  corpuscles  by  the  megaloblastic 
process  is  obviously  a  much  slower  one.  The  fact  that  megaloblasts 
only  occur  in  small  numbers  in  the  blood,  while  the  normoblasts, 
as  has  been  stated,  frequently  are  found  in  very  large  numbers, 
speaks  strongly  in  favour  of  this  contention.  Accordingly 
megaloblastic  blood  crises  in  connection  with  antemia  are  not  met 
with.  (2)  Because  the  megalocytes,  which  are  derived  from  the 
megaloblasts,  possess  in  proportion  to  their  volume  a  relatively 
small  respiratory  surface,  and  on  this  account  must  be  regarded 
as  a  purposeless  type  in  anaemic  conditions.  This  beeomes  all  the 
clearer  when  it  is  remembered  that  the  formation  of  poikilocytes 
represents  a  purposeful  process. 

The  megaloblastic  degeneration  of  bone  marrow  must  be 
ascribed  to  the  fact  that  the  marrow  is  subjected  to  chemical 
influences,  which  alter  the  regeneration  type  in  a  purposeless 
manner.  The  originating  agencies  of  these  toxic  processes  are  to 
a  great  extent  still  unknown.  For  this  reason  it  is  impossible 
to  stop  the  process,  and  the  disease  necessarily  terminates  in 
death.      This   view   has    received   considerable  support    in    the 

■'  It  may  be  advisable  to  emphasise  that  what  has  been  said  with  regard  to  tlic 
diagnostic  importance  of  megaloblasts  only  applies  to  the  blood  of  adults,  the 
conditions  met  with  in  the  blood  of  children,  which  differs  in  many  respects  from 
that  of  adnlts,  will  be  dealt  with  separately  under  another  heading  (infantile 
pseudo-leukajmic  anaemia). 


78  ANJEMIA 

pathology  of  bothriocephalus  ansemia,  which,  as  is  well  known, 
offers  a"  favourable  prognosis  in  general.  This  form  occupies  an 
exceptional  position  among  the  ansemias  of  a  megaloblastic  type, 
for  the  sole  reason  that  its  cause  is  known  and  can  be  removed. 
Different  individuals  react  in  different  ways  toward  the 
bothriocephalus,  just  as  they  do  toward  many  infective  microbes. 
Some  persons  are  not  affected  at  all  by  this  worm ;  others  show 
all  the  appearance  of  a  simple  ansemia,  possibly  with  normo- 
blasts; while  a  third  group  reveals  the  typical  characters  of 
a  pernicious  ansemia.  The  last-named  type  may  be  so  like 
Biermer's  ansemia  that  when  the  cause  is  not  recognised  for 
years  there  are  no  means  of  distinguishing  it  from  the  more 
serious  condition.  It  is  therefore  not  going  too  far  to  regard 
severe  bothriocephalus  ansemia  as  a  pernicious  ansemia  with  a 
known  and  removable  cause.  Schauman's  detailed  monograph 
offers  the  fullest  proof  for  this  conception. 

Even  if  a  detailed  discussion  of  this  highly  important  question 
really  belongs  to  the  clinical  part  of  this  work  (see  Vol,  II.),  one 
other  fact  at  least  should  be  mentioned  in  this  place,  which 
illuminates  the  condition  very  strikingly.  Bothriocephalus 
ansemia  and  ankylostomum  ansemia  are  two  conditions  which 
are  very  closely  allied,  clinically  speaking.  But  a  remarkable 
difference  between  them  is  brought  to  light  when  the  blood  of 
persons  suffering  from  these  two  conditions  is  examined.  Even 
in  its  milder  forms  the  blood  of  bothriocephalus  ansemia  patients 
frequently  contains  megaloblasts  and  megalocytes,  the  important 
characteristics  of  progressive  pernicious  ansemia;  the  blood  of 
ankylostomum  ansemia  patients,  even  in  fatal  cases,  merely  shows 
the  appearances  of  a  simple  severe  ansemia  (Sahli,  Eosenqvist, 
Schauman,  Liermberger).  The  difference  depends  on  the  fact 
that  bothriocephalus  stimulates  the  formation  of  megaloblasts  by 
means  of  a  specific  poison,  while  ankylostomum  acts  chiefly  by 
abstracting  considerable  quantities  of  blood  continuously.  In 
the  latter  instance,  as  is  the  case  in  traumatic  ansemia  or  the 
severest  forms  of  post-hsemorrhagic  ausemias  produced  by 
hsemoptysis  or  bleeding   from  a  uterine  myoma,  no  megaloblastic 


THE  MORPHOI.OGY  OF  THE  m.OOl)     79 

degeneration  of  tlio  ni.-uTow  develops.  II-  llms  npprjurK  tliat.  il  Ik 
not  the  severity,  Ijiit  the  kind  of  theaiKciniji,  wliicii  is  c}i;i,i;u;lf;riHr;d 
by  the  v.arious  kinds  of  erythroljlasts. 

The  occurrence  of  megaloblasts  in  po'iiicious  uua'mia  niuBt  be 
interpret(Ml  in  tliis  manner.  The  megaloblastic  degeneration  of 
the  bone  marrow  depends  solely  on  the  jjrcsonce  of  definite 
noxious  agents,  the  nature  of  which  is  unfortunately  not  yet 
known.  If  it  were  possible  to  remove  these  agencies  it  would  a 
priori  be  quite  certain  that  the  bone  marrow  could  regain  its 
normal  normoblastic  regeneration  type,  provided  that  the 
disease  had  not  advanced  too  far.  Clinical  observation  shows 
this  quite  clearly  in  certain  cases.  It  is  by  no  means  a  rare 
occurrence  for  an  apparent  cure  of  a  megaloblastic  ansemia  to 
occur,  but  after  a  shorter  or  longer  period  the  symptoms 
reappear,  and  then  lead  with  certainty  to  a  fatal  termination. 
Such  cases,  and  every  observer  has  an  opportunity  of  seeing 
them,  prove  that  the  megaloblastic  degeneration  as  such  may 
regress.  In  some  cases  the  usual  arsenic  treatment  suffices 
to  produce  this  result.  A  definite  cure  cannot  be  achieved 
under  these  conditions,  because  the  aetiological  agent  is  unknown, 
and  therefore  cannot  be  removed.  It  may  be  stated  that  the 
prognosis  of  the  megaloblastic  anaemias,  with  the  exception  of 
bothriocephalus  anamia,  is  a  hopeless  one. 


BIBLIOGRAPHY. 

Abderhalden.— "  Beitriige  zur   Frage  nacli   der  Einwirkung  des  Hohen- 

klimas  auf  die  Zusammensetzmig  des  Blutes,"  Zeitsclir.f.  Biol.,  vol.  xliii. 
Albrecht,  E. — "  Ueber  den  Untergang  der  Kerne  in  den  Erythrobla?ten  der 

Siiugetiere,"  Inaugural  Dissertation,  Munich,  1902. 
Arnold. — "  Ueber  Granitlafarbung  lebender  und  iiberlebender  Leucocyten," 

Virchoio's  Arcliiv,  1899,  vol.  clvii. 
AsKANAZY,  S. — "Ueber  einen  interessanten  Blutbefund  bei  rapid  letal  ver- 

laufender  pernizioser  Anaemie,"  Zeitschr.  f.  hlin.   Mcdizin,    1893,    vol. 

xxiii. ;  "  Ueber  die  Kornung  der  roten  Blutkorperchen  bei  anaemisclien 

Zustauden,"  Zeitsclir.f.  Jclvn.  Medizin,  1907. 
Benario. — "  Nocli  einmal  die  Leukozyetnscliatten  Kleins,"  Deutsches  vied. 

JFochenschr.,  1894,  No.  27. 


80  ANAEMIA 

Bencb. — "  Drei   Falle  von  Polyglobulie,"  Deibtsche  mecl.   Wochenschr.,  1906, 

No.  37. 
Bettmann. — "  jUeber    den    Einfluss   des   Arseniks  auf  das    Blut  tind   das 

Knochenmark    des    Kaninchens,"    Beitr.    z.    pathol.    Anat.    u.    allgem. 

Pathol,  1898,  vol.  xxiii. 
BiERNACKi. — ^"  Untersuchungen  liber   die  chemische  Blutbeschaffenbeit  bei 

pathologischen,   insbesondere  bei  anaemischen  Zustanden,"  Zeitschr.  f. 

Jdin.  Medizin,  1894,  vol.  xxiv.  (full  Bibliography). 
Bleibtreu,  L. — "  Kritisches  iiber  den  Haematokrit,"  Berl.  hlin.  ?Fochenschr., 

1893,  Nos.  30,  31. 
Bleibtreu,  M.  and  L. — "  Eine  Methode  zur  Bestimmung  des  Volumens  der 

korperlichen  Elemente  im  Blut,"  Ffliiger's  Archiv,  1892,  vol.  li. 
Blix-Hedin. — Scandinavian  Pathological  Archives,  1890,  p.    134  (quoted  by 

Limbeck). 
Block,  E. — "  Beitrage  zur  Haematologie,"  Zeitschr.  f.  klin.  Medizin,  1901, 

vol.   xliii.    "ZurKlinik  und  Pathologie  der  Biermerschen  progressiven 

Anaemie,"   Deutsches   Arch.  f.  Idin.   Medizin,  vol.   Ixxvii.    "  Ueber   die 

Bedeutung  der  Megaloblasten  und  Megalozyten,"  Beitr.  z.  pathol.  Anat. 

u.  allgem.  Pathol.,  1903,  vol.  xxxii. 
BoRCHARDT. — rContributiou  to  Berlin  Medical  Society  Transactions,  1899,  vol. 

xix.  p.  179. 
BouRRET. — "  Contribution  a  I'etude  des  hematies  et  granulations  basopldles 

dans  le  Saturnisame  experimental."     These  de  Bordeaux,  1901. 
Breuer. — "  Ueber    eine    Farbungsmethode,    mit    der   man    Diabetes    und 

Glykosurie    aus   dem   Blute  diagnostizieren   kann,"   Zentralbl.   d.   med. 

Wissenschaft,   1894,  No.  49  ;  "  Die  Diagnose  des  Diabetes  mellitus  aus 

dem  Blute  mittels   Anilinfarben,"   Zentralbl.  f.   innere  Medizin,    1897, 

No.  22. 
Cabot. — Journal  of  Medical  Research,  1903  (quoted  by  Schleip). 
CoHNSTEiN  AND  ZuNTZ. — "  Untersuchungen  iiber  den  Fllissigkeitsaustauscli 

zwischen  Blut  und  Geweben  unter  verschiedenen  physiologischen  und 

pathologischen  Bedingungen,"  PJliige7-'s  Archiv,  1888,  vol.  xlii. 
Dammer. — "  Ueber  die  Ursachen   der  Bremerschen   Keaktion,"   Inaugural 

Dissertation,  Jena,  1900  (Bibliography). 
DiEBALLA. — •"  Ueber  den  Einfluss  des  Haemoglobingehaltes  und  der  Zahl 

der    Blutkorperchen    auf    das    spezifische     Gewicht     des     Blutes     bei 

Anaemischen,"  Deutsches  Arch.f.  klin.  Medizin,  1896,  vol.  Ivii. 
Dietrich. —  "Die  Bedeutung  der  Dunkelfeldbeleuchtung  fiir  die  Blutunter- 

suchung,"  Berliner  hlin.  Wochenschr.,  1908,  No.  31. 
Douglas. — "  A  Method  for  the  Determination  of  the  Volume  of  Blood  in 

Animals,"  Journ.  of  Physiol.,  1906,  vol.  xxxviii. 
DuNiN. — "  Ueber    anaemischen    Zustanden,"    Leipzig,    1895.     (Volkmann's 

Collection  of  Clinical  Lectures,  new  series.  No.  135.) 
Egger. — "  Ueber  die   Untersuchung   der   Blutkorperchen   beim  Aufenthalt 

im  Hochgebirge,"  Korrespondenzbl.  f.  Schweiaer  Aerzte,  1892,  vol.  xxxii. 

p.  645,  and  Medical  Congress,  1893,  vol.  xii. 
^'ERhlCK.—Farbe7ianalytische    Untersuchungen  zur  Histologic  und  Klinik  des 

Blutes,    Berlin,    1891;    "Ueber    schwere    anaemische   Zustande,'"    XI. 


THE  MORPIIOLOGY  OF  TFIK  lU.OOI)     Rl 

Medical  CongrcHs,  1892.     "  Do-  und  Ko-generatioii  rotor  JilulschcilK'.n," 

Verhandl.  d.  Gesellsch.  d.  Charit^-Aerde,  June  10  and  JJeconiber  9,  1880. 
Ehrlich,    Frkuichs. — "  Ueber   das    Vorkomnien    von    Glycogen    irn   dia- 

betisclicn   nnd   im   normalcn   Organisimis,"  Zr/itHchr.   f.    Jclin.    Mndizin, 

1883,  vol.  vii.  p.  ?,?>. 
Enqbl,  C.  S. — "  Ueber  enibryonale  und  paUiologisclie  rote  Blutkorperchon," 

Berlin  Medical  Society  TravMictionn,  1899,   vol.  i.     "  Ueber  einern  Fall 

von  pernizioser  Anaemie,"  Zeituchr.  f.  klin.  MedAzin^  vol.  xl.  ;  Leitfaden 

zur  Idin.  Untersuchunfj  des  Bluten,  3rd  Edition,  Berlin,  1908. 
Eykmann. — "  Blutuntersucliungen   in   den  Tropen,"    Virchoiv's  Archiv,  vol. 

cxxvi.  i>.  113. 
Fano  (quoted  by  Limbeck). 
FoA,  C. — "  I  mutamenti  del  sangue  sull'  alta  montagna,"  Abstract  in  F(jlia 

Haem.,  1904,  p.  344. 
Friedenthal.^ — Arbeit,    aus    dem     Gehiete     der     ex2Jerimentellen     Patholotjie, 

Jena,  1908. 
Gabriel. — "  Ueber  Ringkorper  im   Blut  Anaemischer,"  Deutsches  Arch.  f. 

hlin.  Medizin,  1908,  vol.  xcii. 
Gabritschewsky. — "  Kliniscli-liaematologische    Notizen,"    Arch.   f.    expcri- 

mentelle  Pathologie  und  Pharmacie,  1891,  vol.  xxviii. 
Gartner,   G. — "  Ueber    eine   Verbesserung   des    Haematokrit,"'   Berl.    hlin. 

Wochenschr.,  1892,  No.  36. 
Georgopulos. — "  Ueber  den  Einfluss  des  "Wassergebaltes  des  Blutes  auf  die 

Dimensionen  der  roten  Blutkorperchen,"  Zeitschr.  f.  klin.  Medizin,  1906, 

vol.  Iviii. 
Giemsa. — "  Farbungsmethode  fiir   Malariaparasiten,"  Zentrulhl.  f.  BakterioL, 

1902,  vol.  xxxi. 
Glogner. — "  Ueber  das  spezifisclie  Gewicht  des  Blutes  des  in  den  Troj^en 

lebenden  Europiiers,''  Virchoid's  Archiv,  vol.  cxxvi.  p.  109. 
Le  Gopp. — "  These  de  Paris,"  1897  (quoted  by  Bezangon  and  Labbe). 
GoTTSTEiN. — "  Ueber  Blutkorperchen  und  Luftdruck,"  Berl.  klin.  TFochenschr., 

1898,  No.  20. 
Grawitz,  E. — "  Ueber  die  Einwirkung  des  Hohenklimas  auf  die  Zusam- 

mensetzung  des   Blutes,"   Berl.   klin.    TFochenschr.,    1895,   Nos.  33   and 

34.      Klinische     Pathologie    des    Blutes,    3rd    Edition,    Leipzig,    1906. 

"  Kliniscli-experimentelle  Blutuntersuchungeu,"  Zeitschr.  f.  klin.  Medizin, 

1891,    vols.    xxi.   and   xxii.     "  Ueber  kornige   Degeneration  der  roten 

Blutzellen,"  Deutsche  med.  TFochenschr.,  1899,  No.  36. 
Grawitz,  E.,   and  GrOneberg. — "  Die  Zellen  des  menschlichen  Blutes  im 

ultravioletten  Lichte,"  Leipzig,  1906. 
Haldane  and  Lorrain-Smith. —  "The  Mass  and  Oxygen   Cajjacity  of  the 

Blood  in  Man,"  Journ.  of  Physiol.,  1900,  vol.  xxv. 
Hammerschlag. — "  Ueber  das  Verhalten   des   sj)ezifischen   Ge-wichtes    des 

Blutes   in   Krankheiten,"    Zentralbl.   f.   klin.    Medizin,    1891,    No.    44. 

"Ueber  Hydraemie,"  Zeitschr.  f.  klin.  Medizin,  1892,  No.  21.     "Ueber 

Blutbefund  bei  Chlorose,"  TT-ien.  med.  Presse,  1894,  No.  27. 
Hartwig. — "  Ueber  die  Farbenreaktion  des  Blutes  bei  Diabetes  mellitus," 

Deutsclies  Arch.f.  klin.  Medizin,  1899,  vol.  Ixii. 


82  AN.EMIA 

Hayem. — Du  sang,  Paris,    1889.     "  Dii  caillot   non   retractile.     Supression 

de  la  formation  du  serum  sanguin  dans  quelques  etats  pathologiques," 

Acad,  des  sciences,  1896,  November  23  (Sem.  me'dic).    "  Des  globules  rouges 

a  noj^au  dans  le  sang  de  I'adulte,"  Arch,  de  Phys.  normale  et  Pathologie, 

3rd  Series,  1883,  vol.  i. 
Heidenhain,  M. — "  Neue  Untersuchungen  liber  die  Zentralkorper,"  u.s.w., 

Archiv  f.  miJcrosJc.  Anatomie,  1894,  vol.  xliii.  p.  515. 
Helly. — Die  hcoematopoetischen  Organe,  Vienna,  1906. 
Herz,  Max. — "  Blutkrankbeiten,"  Virchow's  Archiv,  vol.  cxxxiii. 
Hoppe-Seyler. — "  Verbesserte  Methode  der  kolorimetrischen  Bestimmungen 

des    BlutfarbstofFgehaltes    im    Blute   und    in  anderen   Fliissigkeiten," 

Zeitschr.  f.  phys.  Ghemie,  vol.  xvi. 
Howell. — "  The  Life  History  of  the  Formed  Elements  of  the  Blood,"  etc. 

(quoted  by  H.  F,  Miiller). 
Israel  and  Pappenheim. — "  Ueber  die  Entkernung  der  Saugetiererythro- 

blasten,"  Virchow's  Archiv,  vol.  cxliii. 
VON   Jaksch. — "  Ueber   die   Zusammensetzung    des    Blutes  gesunder    und 

kranker  Menschen,"  Zeitschr.  f.  Min.  Medizin,  1893,  vol.  xxiii. 
Jakcso  and  Rosenberger. — "  Blutuntersuchungen  bei  Malaria,"    Deutsches 

Arch.  f.  Min.  Medizin,  vol.  Ivii.  p.  449. 
Jaquet   and   Suter. — "  Ueber   die    Veranderungen   des   Blutes  im    Hoch- 

gebirge,"  Korrespondenzbl.  f.  Schweizer  Aerzte,  1898. 
VON   Jaruntowsky  and    E.    Schroder. — "  Ueber    Blutveranderungen  im 

Gebirge,"  Milnchen.  med.  Wochenschr.,  1894,  No.  48. 
Jenner. — "A  New  Preparation  for  Rapidly  Fixing  and   Staining  Blood," 

iancee,.1899,  i.  p.  370. 
JiJNGER. — "  Ueber  kernhaltige  rote  Blutkorperchen  im  stromenden  mensch- 

lichen  Blute,"  Deutsches  Arch.f.  Min.  Medizin,  vol.  Ixvii. 
Klebs. —  Vide  XI.  Medical  Congress.     Discussion. 
Klein. — "  Die  Regenerationfahigkeit  des  Organismus  bei  den  verschiedenen 

Varietaten  der  Anaemic,"  Wien.  med.  Presse,  1896,  No.  28. 
KoLLiKER. — "  Entkernung  der  Erythrozyten,"  Zeitschr.  f.  rationelle  Medizin 

(quoted  by  E.  Neumann). 
KoEPPE. — "  Ueber     Blutuntersuchungen    im     Gebirge,"     Medical     Congress 

Transactions,  1893,  vol.  xii.     "  Ueber  Blutuntersuchungen  in  Reibolds- 

griin,"  Munchen.  med.    Wochenschr.,   1895.     "  Ueber  den  Quellungsgrad 

der  toten  Blutseheiben  durch  aquimolekulare  Salzlosungen  und   iiber 

den  osmotischen  Druck  des  Blutplasmas,"  Arch.  f.  Anatom.  u.  Physiol., 
Physiol.  Part,  1895,  p.  154. 
KtJNDiG. — "  Ueber   die    Veranderungen    des   Blutes    im    Hochgebirge    bei 
Gesunden   und    Lungenkranken,"    Korrespondenzbl.    f.    Schweiz.   Aerzte, 
1897,  Nos.  1  and  2. 
Laache. — Die  Anaemic,  Christiania,  1883. 

Laker.- — "  Ueber  eine  neue  klinische  Blutuntersuchungsmethode.     (Spezi- 

fische  Resistenz  der  roten  Blutkorperchen.) "     Wien.  med.  Presse,  1890, 

No.  35. 

Landois,  L.—  Lehrbuch  der  Physiologic  des  Menschen,  Vienna  and  Leipzig,  1887. 

Lazarus,  A. — "Blutbefund  bei  pernizioser  Anaemic,"  "  Transactions  of  the 


THE  MORPITOI.OGY  OF  THE  Br.OOD     83 

Berlin    Medical   Society,"   Deutsche    med     Wochenschr.,    No.    23,    1896. 

"  Klinik  der  Anaemien,"  Ncdhnayel's  Handbuch,  vol.  viii.  2,  Vienna,  1900. 
LENOBi;ifl. — Garadhrcs  smii/iolw/iques  du  caillot  et  du  s&um,  PariH  (Steirilieil) 

1898. 
.LlKUMi5EiU)KU. — "Eoiiraj^  ziii'   IJi.'liaii'lliiii^  drr  Aiik>](<.sUjiriia.si.saiia(:iiiii;  iumI 

der  Tropenanaeniien,"  y^f!'/-/. /cdi'/i,  IFochevsrhr.,  lOOr*,  No.  14. 
V.     LiMiJKCK. —  Ch-undriss     cincr     kliniachcn     I'athobxjie      dea      JHiUch,     2iid 

Edition,  ,Jena,  18!iG.     "  Teljerdie  durcli  (jrallc.ii.staiiurig  bewirktfji  Voriin- 

derungen  des  Blntos,"  Zcnlralbl.f.  innere  Medizin,  189G,  No.  33. 
LiTTEN.— "  Ueber  einige  Veriinderungeu  roter  Blutkorperchen,"  Berl.  hlin. 

Wochenschr.,    1877,    No.    1.       "  Ueber  basophile    Kornungen   in   roten 

Blutkorperchen,"  Deutsche  med.  Wochenschr.,  1899,  No.  44. 
LoKWY,  A.—"  Ueber  Veriinderungen  des  Blutes  durch  thermische  Einfliisse," 

Berl.  Iditi.   Wochenschr.,  1890,  No.  4.     "Die  Wirkung  des  Hohen-  und 

Seeklinias  auf  den   Menschen,"  Berl.  Med.   Society  (1903)  Transactions, 

vol.  xxiii. 
LOEWY,  A.,  J.  LoEWY,  L.  ZuNTZ.— "  Ueber  den  Einfiuss  der  verdiinnten  Luft 

und  des  Hohenklimas  auf  den  Mensclien,'Mrc/i.  /.  d.  ges.  Physiol,  1897, 

vol.  Ixvi. 
LoEWY,  J. — "  Ueber  das  Verhalten  des  diabetischen  Blutes  v.w  den  Anilin- 

farbstoffen,"  Fortschr.  d.  Medizin,  1898,  vol.  xvi. 
Maragliano.— "Beitrag  zur  Patliologie  des  Blutes,"  XI.  Medical  Congress, 

1892. 
Massloff.— "  Einige  Bemerkungen  zur  Morphologic  und  Entwicklung  der 

Blutelemente,"  Arckiv  f.  mikrosk  Anat.,  1898,  vol.  li. 
May  and  Grunwald.— "  Ueber  Blutfjirbungen,"  Zentmlhl.  f.  innere  Medizin, 

1902,  No.  11. 
Mayer,    Karl    Hermann.— "  Die    Fehlerquellen    der    Haemometerunter- 

suchung  (v.  Eleischl),"  Deutsches  Arch.f.  Min.  Medizin,  vol.  Ivii.  pp.  1,  2 

(full  Bibliography). 
Meissen  and  Schroder.—"  Eine  vom  Luftdrucke  unabhangige  Zahlkammer 

fiir  Blutkorperchen,"  Miinchen.  med.  Wochenschr.,  1898,  No.  4. 
Mercier. — "  Des  modifications  de  nombre  et  de  volume  que  subissent  les 

erythrocytes  sous  I'influence  de  I'altitude,"  Archives  de  2}hysiol,  5th  Ser., 

1894,  vol.  vi.  p.  769. 
Meyer  and  Heineke.—"  Ueber  den  Farbeindex  der  roten  Blutkorperchen," 

Miinchen.  med.  Wochenschr.,  1906,  No.  17. 
Meyer  and  Speroni.—"  Ueber  punktierte   Erythrocyten,"  Miinchen.    med. 

Wochenschr.,  1906,  No.  17. 
MiCHAELis,  L.— Berl.  Medical  Society,  1899-1900,  p.  49  of  Transactions.  "  Eine 

Universalfarbemethode  fiir   Blutprtiparate,"  Deutsche  med.    Wochenschr., 

1899,   No.    30.    "Das  Methylenblau    und   seine   Zersetzungsprodukte," 

Zentralhl.  f.  BaUeriol.,  1901,  vol.  xxix. 
MiESCHER. — "  Ueber  die  Beziehungen  zwischen  ]\Ieereshohe  und  Beschaffen- 

heit  des  Blutes,"  Korrespondenzbl.f.  Srhweizcr  Aerzte,  1892,  xxiii.  p.  809. 
MoRAWiTZ. — "Klinische  Untersuchungen  ueber  Blutverteilung  und   Blut- 

menge  bei  Gesunden  und  Kranken,"   Volkmann''s  Clinical  Lectures,  No. 

462,  1907. 


84  ANEMIA 

Naegeli.— "Ueber  die  Entstehimg  der  basophil  gekornten  roten  Bliitkor- 
perchen,"  Munchen.  med.  JVochenschr.,  1904,  No.  5.  "Ueber  basopliile 
Granulation  ■  der  Erytlirocyten  bei  Embryonen,"  Fol.  haemat,  1908,  p. 
525.  BluthranMieiten  und  Blutdiagnostik,  Leipzig,  1907. 
Neumann,  E.— "  Ueber  Blutregeneration  und  Blutbildung,"  Zeiischr.  f.  Uin. 
Medizin,  1881,  vol.  iii. 

Neusser. — "Ueber  einen  besonderen  Blutbefund  bei  uratischer  Diathese,'' 
Wien.  Jdin.,  1892,  Nos.  3  and  4. 

V,  NooRDEN. — "  Untersuchungen  liber  scbwere  Anaemie,"  Annals  of  the 
Berl.  Charite,  1889,  vol.  xvi. 

Orum. — "  Quantitative  Blutuntersuchuugen,"  Deutsches  Arch.  f.  klin. 
Medizin,  1908,  vol.  xciii. 

Pappenheim. — "  Die  Bildung  der  roten  Blutscheiben,"  Inaugural  Dissertation, 
Berlin,  1895  (full  Bibliography).  "Ueber  Entwicklung  und  Aus- 
bildung  der  Erythroblasten,"  Archiv  f.  patholog.  Anat.,  vol.  cxv. 
"  Dunkelfeldbeleuchtung,"  Fol.  haem.,  1908,  vol.  vi.  S.  190.  "Ver- 
gleichende  Untersuchungen  liber  die  elementare  Zusammensetzung 
des  roten  Knochenmarkes  einiger  Saugetiere,"  Virchow's  Archiv, 
1899,  vol.  clvii. 

Perles. — "  Beobachtungen  liber  perniziose  Anaemie,"  Berl.  Uin.  Wochenschr., 
1893,  No.  40. 

Ppeiffer,  Th. — "  Ueber  die  Bleibtreusche  Methode  zur  Bestimmung  des 
Volumens  der  korperlichen  Elemente  im  Blute  und  die  Anwendbarkeit 
derselben  auf  das  Blut  gesunder  und  kranker  (insbesondere  fiebernder) 
Menschen,"  Zentralhl.f.  innere  Medizin,  1895,  No.  4. 

Plehn,  a. — "Ueber  Tropenanaemie,"  u.s.w.,  Deutsche  med.  JVochenschr.,  1899, 
Nos.  28-30. 

Plesch. — "  Chromophotonieter,"  u.s.w.,  Zeitschr.  f.  Idin.  Medizin,  1907,  vol. 
Ixii. 

Quincke. — "  Weitere  Beobachtungen  liber  perniziose  Anaemie,"  Deutsches 
Arch.  f.  klin.  Medizin,  vol.  xx.  "  Zur  Physiologic  und  Pathologie  des 
Blutes,"  Deutsches  Arch.  f.  klin.  Medizin,  vol.  xx.  "  Ueber  Eisentherapie," 
Volkmann^s  Collection  of  Clinical  Lectures,  New  Series,  p.  129. 

Rahlmann. — "  Ueber  einige  Beziehungen  der  Netzhautzirkulation  zu 
allgemeinen  Storungen  des  Blutkreislaufes,"  Virchoid's  Archiv,  vol.  cii. 

Reinert. — Die  Zcihlung  der  roten  Blutkorperchen,  Leipzig,  1891. 

RiNDFLEiscH. — "  Ueber  Kuochenmark  und  Blutbildung,"  Archiv f.  mikroskop. 
Anat.,  1880,  xvii.  p.  1.  "  Ueber  die  Fehler  der  Blutkorperchenbildung 
bei  der  perniziosen  Anaemie,"  Virchow's  Archiv,  1890,  vol.  cxxi.  p. 
176. 

RoMANOWSKY. — "  Zur  Frage  der  Parasitologic  und  Therapie  der  Malaria," 
Petersburger  med.  JVochenschr.,  1891. 

Rosin.- — Berl.  Medical  Society  Transactions,  1899-1900,  p.  49. 

Rosin  and  Bibergeil. — "  Ueber  vitale  Blutfarbung,"  u.s.w.,  Zeitschr.  f.  klin. 
Medizin,  1902,  vol.  liv.  (Bibliogra]3hy). 

Sabrazes  (quoted  by  Naegeli). 

Sachs,  H. — "  Ueber  DifFerenzen  der  Blutbeschaffenheit  in  verschiedenen 
Lebensaltern,"  Zentralbl.  f.  Bakteriol.,  1903,  vol,  xxxiv. 


THE  MORrnOLOGY  OF  THE  lU>OOI)     85 

Sahli. — Klinische    UntersuchumjHmethoden,   4tli    Edition,   1000.      "Jjeitriige 

zur  klinischcn  Gescliichte  der  Anaeinie  der  Gotthardf,iiniiel-Arbf;iter," 

Deutsches  Archivf.  hlin.  Medizin.,  1883,  vol,  xxxii. 
ScHAUMAN. — Zur  Keniiinit  der  sogenannteii,  Bolhrioceph(ilii,ii-Anacmie,  ]3erlin, 

1894. 
ScHAUMAN  and  Ro.sknquist. — "  Ucb(!r  die  Natur  der  J'hitveriinderunj^en  im 

Holienklinia"  (IJiljliography),  Zeiinrhr.  f.  Jcliv..  Medizin,  1898,  vol.  xxxv. 

"Wie   ist  die   Blutkorpercli(;nvernielirung   im    Geliirgi;   zii   erkluren?" 

Therap.  Monatsheftc,  1900,  No.  1. 
SCHIFF. — "Ueber  das  quantitative  Verhalten  der  Bhitkorperchen  und  des 

Haemoglobins  bei  neugeborenen  Kindern  und  Sauglingen  unter  normalen 

und   pathologischen  Verhiiltnissen,"   Zeitschr.  f.   Heilkunde,    1890,  vol. 

xi. 
ScHLEiP. — "Ueber  Ringkorper  im  Blute  Anaemi.sclier,"  Deutsches  Archivf. 

Mill.  Med.,  1907,  vol.  xli. 
Schmaltz. — "  Die  Untersuchung  des  spezifischen  Gewichtes  des  menschlichen 

Blutes,"  Deutsches  Archiv  f.  klin.  Medizin,  1891,  vol.  xlvii.     "  Spezifische-s 

Gewicht    und    Haemoglobingehalt,"   Deutsche    med.    JVochenschr.,    1891, 

No.    16.     Die  Pathologic    des  Blutes  und   die  BlutJcrankheiten,  Leipzig* 

1896. 
Schmidt,  P. — "  Ein  Beitrag  zur  Frage  der  Blutregeneration,"  MUnchen.  med. 

JVochenschr.,   1903,  No.   13.      Experimentelle  Beitrdge  zur  Pathologic   des 

Blutes,  Jena,  1902.    "  Zur  Frage  der  Entstehung  der  basophilen  Kornchen 

in  den  roten  Bhitkorperchen,"  Deutsche  med.  JVochenschr.,  1902,  No.  44. 
ScHUPFNER. — "Beitrag  zur  Kenntnis   der  Malavia,"  Deutsches  Archiv  f.  klin. 

Medizin,  vol.  Ixiv. 
SCHUMBURG  and  N.  Zuntz. — "Zur  Kenntnis  der  Einwirkungen  des  Hoch- 

gebirges    auf   den    menschlichen    Organismus,"    Pfliiger's   Archiv,    1896, 

vol.  Ixiii. 
ScHUR   and    H.    Loewy. — "Ueber    das   Verhalten    des   Knockenmarkes   in 

Krankheiten,"  u.s.w.,  Zeitschr.  f.  klin.  Medizin,  1900,  vol.  xl. 
Sellier. — "  Contribution  a  I'etude  de  Tinfluence  de  la  tension  de  I'oxygene 

sur  I'hematopoiese, "  etc.,  These  de  Bordeaux,  1895  (quoted  by  Schaumau 

and  Rosenquist). 
Lorrain-Smith    and  M'Kisack. — Transactions   of   the  Pathol.   Soc.  London, 

1900  (quoted  by  Parkes-Weber). 
Stierlin. — "  Blutkorperchenzahlung      und     Haemoglobinbestimmung     bei 

Kindern,"  Deutsches  Archiv  f.  klin.  Medizin,  1889,  vol.  xlv. 
Stintzing  and  Gumprecht. — "  Wassergehalt  und  Trockensubstanz  des  Blutes 

beim  gesunden    und   kranken    Menschen,"    Deutsches    Archiv   f.    kbn. 

Medizin,  1894,  vol.  xliii. 
Strauss  and  Rohnstein. — Blutzusammemetzung  hei  verschiedemn  Anaemien, 

Berlin,  1908. 
Tarchanoff,    J.    R. — "Die    Bestimmung    der    Blutmenge    am    lebenden 

•    Menschen,"  Pfliiger's  Archiv,  \o\s.  xxiii.  and  xxiv. 
Thoma  and  Lyon. — "  Ueber  die  Methode  der  Blutzahluug,"  Virclioic's  Archiv^ 

vol.  Ixxxiv. 
Turk. — Klinische  Haematologie,  Vienna,  1904,  vol.  i. 


86  ANJEMIA 

ViAULT. — "  Sur  raugmentation  considerable  du  nombre  des  globules  rouge, 

dans  1-e  sang  cliez  des  habitants  des  hauts-plateaux  de  I'Amerique  du  Sud," 

Compt.  rend.-  de  VAcad.  des  scienc,  vol.  cxi.  p.  917. 
Walker. — The  Journ.  of  Boston  Soc,  November  1899  (quoted  by  Grawitz). 
Parkes-Weber. — "  Die  Zunahme  der  gesamten  Blutmenge  bei  Polycytliaemie, 

U.S.W.,  Fol.  haem.,  June  1908. 
Weidenreich. — "  Studien  liber  das  Blut,"  u.s.w.,  Archiv  f.  mikroslcop.  Anat. 

und  Entwichlungsgesch.,  1903,  vol.  Ixi. 
Wbndelstadt,  H.,  and  L.  Bleibtreu.- — "  Bestimmung  des  Volumens  und  des 

Stickstoffgehaltes  des  einzelnen  roten  Blutkorpercliens  im  Pferde-  und 

Schweineblut,"  Pjiiiger's  Archiv^  vol.  Hi. 
Westphal. — "  Ueber     Mastzellen,"    Inaugural    Dissertation,    Berlin,    1880 

(cf.  Ehrlich,  Farhenanalytische  Untersuchungen,  etc.). 
Williamson. — "A  Simple  Method  of  Distinguishing  Diabetic  from    Non- 
diabetic  Blood,"  Brit.  Med.  Journ.,  1896,  September  19. 
Wolff,   F.,   and    Koppe. — Ueber    Blutuntersuchungen    in    Eeiboldsgriin," 

Miinchen.  mediz.  Wochenschr.,  1893,  No.  11. 
WoLOWNiK.  —  "  Ueber  das  Verhalten  der  Knoclienniarkzellen  bei  verschiedenen 

Krankheiten,"  Zeitschr.  f.  Idin.  Medizin,  1905,  vol.  Ivi. 
Wright. — "Remarks     on    Methods    of    Increasing    and    Diminishing   the 

Coagulability  of  the  Blood,"  Brit.  Med.  Journ.,  1894,  July  14. 
Zangemeister. — "Ein  Ap-pa.Ya.t  fiir  kolorimetrische  Messungen,"  Zeitschr.  f. 

Biologie,  1896,  vol.  xxiii. 
Zenoni. — "Ueber    gas    Auftreten    kernhaltiger    roter    Blutkorperchen    im 

zirkulierenden    Blute,"    VircJioiv's  Archiv,    1895,   vol.    cxxxix.     "Delle 

Alterazioni  degenerative  degli  Eritroblasti,"  Policlinico,  1898. 
ZiEMANN. — "  Die    Methode    der    Doppelfarbung    bei    Flagellaten,"    u.s.w., 

Zentralhl.  f.  Balderiol.,  1898,  vol.  xxiv. 
ZoLLiKOFER  — Inaugural  Dissertation,  Bern,  1899  (quoted  by  Naegeli). 


CHAPTER    III 

THE  WIHTi:  BLOOD  COIil»USCLES 

The  biological  siguificiince  of  the  while  blood  corpuHcles  is  so 
varied  that  these  cells  represent  the  most  interesting  chapter 
in  hsBmatology.  They  are  motile  elenjents,  which  reveal  con- 
siderable changes  in  response  to  comparatively  slight  stimuli. 


Fig.  2. — Fe.'VYIng  of  the  Peotoplasmal  Investment  of  Lymphocytes; 

SEPARATION    OF    THE   FREE    PlASMA    ELEMENTS   (PlASMOLYSIS).       (After 
a  Photograph  of  a  Fihii  from  a  Case  of  Chronic  Lj'mphatic  Leuk<emia.) 


ANtEMTA 


Fig.  3. — Nucleoli  in  the  larger  Lymphocytes.     (After  a  Photograph  of 
a  Film  from  a  Case  of  Chronic  Lymphatic  Leukaemia.) 


Fig.  4  (From  Eieder's  Atlas), — Transformation  of  the  Nuclei  of  the 
Lymphocytes.     (Appearance  of  the  Blood  in  Acute  Leukaemia.) 


THE  WHITE  BTX)OD  CORPUSCLES 


Hi) 


Hsematologiste  have  only  f^radually  learned  to  recogniHC  tlial 
the  white  blood  corpuscles  play  an  important  part  in  the 
physiology  and  pathology  of  the  human  organism.  It  was 
obviously  thought  to  be  unnecessary  to  asci'ibe  impoitaiit 
functions  to  elements  which  were  present  in  relatively  small 
numbers  in  the  blood. 

Virchow's  discovery  of  leukcemia  was  the  first  step  toward 
the  recognition  of  the  importance  of  the  wliite  blood  corpuscles 
in  pathology.  In  the  next  place,  the  discovery  by  Cohnheim 
of  the  fact  that  inflammation  and  suppuration  were  due  to 
a  migration  of  white  blood  corpuscles  awakened  a  great 
interest  in  the  leucocytes.  The  result  of  the  observations  of 
inflammatory  processes  was  of  such  a  character  as  to  throw 
a  certain  light  on  normal  conditions.  Thus  the  fact  that  in 
diff'use  inflammations  large  quantities  of  pus  were  often  formed 
without  impoverishing  the  blood,  as  far  as  leucocytes  were  con- 
cerned, but  rather  tending  to  increase  these  cells,  gave  rise 
to  the  assumption  that  the  site  of  origin  of  the  leucocytes 
must  be  extraordinarily  productive,  and  that  in  contrast  to  the 
red  blood  corpuscles  the  small  number  of  white  cells  was  fully 
compensated  by  a  great  capability  of  regeneration. 

Nevertheless  it  took  a  long  time  before  the  powerful  impulse 
given  by  Cohnheim  yielded  tangible  results  for  clinical  histology. 
As  has  already  been  mentioned,  the  methods  of  blood  examination 
in  use  up  to  that  time  rendered  it  extremely  difficult  to  form 
an  exact  difterentiation  of  the  various  forms  of  leucocytes. 
This  fact  was  responsible  for  the  stagnation  in  the  knowledge 
of  the  leucocytes  at  that  time.  Even  if  such  eminent  in- 
vestigators as  Wharton  Jones  and  Max  Schultze  were  able  to 
describe  various  types  of  white  blood  corpuscles,  their  work 
failed  to  make  an  impression  on  clinical  practice,  because  the 
differential  criteria,  by  means  of  which  they  distinguished  the 
types,  were  much  too  subtile  and  were  not  suitable  for  clinical 
examination.  Virchow,  who  discovered  leucocytosis,  ascribed 
this  condition  to  an  increase  in  the  number  of  lymphocytes, 
although,  as   is    now    recognised,    the    polynuclear    cells    alone 


90  ANAEMIA 

contribute  to  its  production.  It  was  therefore  only  after  the 
introduction  of  dry  films  and  staining  methods,  which  rendered 
the  differentiation  quite  easy,  that  a  great  interest  was  taken 
in  the  white  blood  corpuscles.  The  astoundingly  voluminous 
literature,  especially  on  leucocytosis,  is  a  proof  of  this. 

The  endeavour  to  divide  the  various  leucocytes  from  one 
another,  and  where  possible  to  trace  them  back  to  their 
separate  sites  of  development,  owed  its  origin  to  Virchow's 
recognition  of  the  lymphocytes,  and  was  first  thoroughly  realised 
when  Ehrlich  classified  these  cells  with  exactitude.  The 
correctness  of  this  principle  has  by  now  been  generally  acceded, 
and  it  has  borne  rich  fruits,  especially  in  clinical  medicine. 
There  are  still,  it  must  be  admitted,  a  few  authors  who  strive 
to  modify  the  sharply  dividing  lines  in  their  endeavour  to 
introduce  an  alleged  simplification.  These  authors  try  to  show 
that  the  various  forms  of  leucocytes  are  only  various  phases 
and  developmental  stages  of  the  same  species  of  cell.  Such 
views,  however,  are  incapable  of  replying  to  the  objections 
raised  by  morphological  or  biological  criticism,  and  it  is  certain 
that  within  a  short  time  not  a  single  earnest  observer  will  hold 
these  views. 


I.  NORMAL  AND  PATHOLOGICAL  HISTOLOGY  OF  THE 
WHITE  BLOOD  CORPUSCLES. 

The  classification  of  the  white  blood  corpuscles  in  general 
use  to-day  is  that  which  has  been  constructed  on  Ehrlich's 
suggestions,  and  morphological,  physical,  and  chemical  attributes 
have  been  taken  into  account  in  formulating  it.  A  definite 
kind  of  cell  is  characterised  by  a  number  of  properties.  These 
criteria  are  so  constant  and  reliable  that  every  experienced 
observer  is  able  to  recognise  the  variety  of  cell  at  a  glance. 

1.  The  Lymphocytes. — These  are  small  cells,  being 
usually  of  about  the  same  size  as  red  blood  corpuscles.  The 
nucleus  occupies  the  greater  part  of  the  cell,  and  is  round  or 
oval   in   shape.     The   nucleus    is   centrally   placed   in  the  small 


THE  WHITE  15LOOD  CORPUSCLES      91 

obviously  young  i'orniH,  while  it  is  excentrically  situated  in  the 
older  and  large  cells,  so  that  a  hroad  niasK  of  ])i'oif>j)l;LKiii  is 
visible  at  one  side. 

The  nucleus  stains  intensely  with  iill  the  basic  dyes,  and 
reveals  a  dense  chromatin  network.  Wlien  suitably  stained  (the 
best  for  this  purpose  is  ^lyronin  methyl-green)  a  distinct 
nucleolus  is  rendered  visible,  with  a  relatively  broad  highly 
coloured  membrane ;  rarely  two  such  nucleoli  are  seen.  The 
nucleus  often  presents  a  notch,  and  in  older  types  is  not  round, 
but  rather  of  a  long  oval  shape.  This  cell  never  shows  that 
peculiar  polymorpho  -  nuclear  structure  which  is  met  with  in 
other  leucocytes,  but  possesses  a  more  or  less  round  nucleus 
throughout  its  whole  existence.  Only  under  very  rare  patho- 
logical conditions  does  the  lymphocyte  have  peculiar  lobulated 
nuclear  structures,  and  it  is  then  known  as  the  "  Eieder's  cell " 
of  lymphatic  leukaemia. 

The  protoplasm  is  usually  very  narrowly  developed.  In 
the  larger  specimens  it  is  broad,  and  then  reveals  a  basophile 
reticulum,  in  which  the  crossings  of  the  meshes  are  so  prominent 
that  Ehrlich  at  first  regarded  them  as  granules.  When  ex- 
amined under  a  high  magnifying  power  it  will  be  seen  that 
there  are  no  isolated  nodules. 

A  pale  area  is  seen  between  the  nucleus  and  the  protoplasm, 
in  which  the  protoplasmal  reticulum  is  only  very  faintly  out- 
lined. In  this  area  in  every  lymphocyte  the  fuchsinophile 
granules,  which  were  discovered  by  Schridde,  are  placed.  They 
are  demonstrable  by  means  of  Altmann-Schridde's  staining. 
Since  this  method  of  staining  has  not  yet  been  included  in 
Helly's  treatise,  it  should  be  described  in  this  place. 

(a)  INIethod  op  preparing  the  Film — 

1.  The    blood    is  smeared    on  to  the  cover-sHp    in    a    thin 

layer. 

2.  The  cover-glasses  are  tlieu  placed  for  one  to  two  hours 

iu  formol-Miiller  (1  :  9). 

3.  They    are    then    rinsed   first   for    several  minutes    with 

tap  water,  and  then  with  distilled  water 


92  ANEMIA 

4.  They  are  then  immersed  for  half  an  hour  in  the  dark 
in  1  per  cent,  osmic  acid. 
'  5.  IS^ext,  they  are  rinsed  for  a  short  time. 

6.  They   are   then    stained   with    Altmann's    anihn    acid 

fuchsin  solution  (100  c.c.  of  cold  saturated  filtered 
solution  of  anilin  in  distilled  water  with  20  grms. 
of  acid  fuchsin. — Filtration).  This  solution  is  poured 
on  to  the  cover-glass,  which  is  then  warmed  five  or 
six  times  over  the  flame  until  the  solution  begins 
to  steam,  and  then  put  aside  until  cool. 

7.  After   the   dried   stain    on   the    edges  of  the  film  have 

been  removed  with  filter  paper  the  films  are  diff"er- 
entiated  with  alcoholic  picric  acid  (saturated  solution 
of  picric  acid  in  alcohol,  1  part  in  7  parts  of  20  per 
cent,  alcohol).  This  solution  is  dropped  on  to  the 
film  several  times,  until  it  appears  yellowish  or  pale 
yellow. 

8.  The  specimen  is  then  rinsed  rapidly  with  absolute  alcohol. 

9.  It  is  then  passed  through  toluol  or  xylol,  and 
10.  Mounted  in  Canada  balsam. 

The    eosinophile     granules    are    dark    red,    the 

neutrophile  (amphophile),  granules  pale  brownish  red, 

the  basophile  granules  colourless,  like  vacuoles.     The 

lymphocytes  show  perinuclear   granules    or  rodlets    of 

a  yellow  crimson-red  colour. 

{b)    Method     of     demonstrating     the     Cell     Granulation    in 

Sections  (including  lymphocyte  granules). — The  tissues,   while   warm 

and  fresh,  are  fixed  in  formalin-Muller    (1  :  9)  for  twenty-four   hours 

at  36°  C.      They  are  then  washed  for  twenty-four  hours.      Next,  they 

are  passed  through  alcohol,    60,    70,    85,    96    per   cent.,  and   absolute 

alcohol,  toluol  (in  each  one  hour),  paraffin  (altogether  one  and  a  half 

to  two  hours).     The  sections  should  be  1  or  2  /x,  in  thickness. 

1.  The    sections   are   floated    on    1    per    cent,    osmic   acid 

solution  for  one  hour  in  the  dark. 

2.  JS^ext  they  are  rinsed  in  distilled  water. 

3.  ISText  they  are  stained  in  Altmann's  solution  (see  above). 

4.  They  are  then   diff'erentiated  with  alcoholic  picric  acid 

solution,  as  described  above. 


THE  WHITE   HT.OOn  CORiniSCr.ES      03 

5.  They   are  then   taken    through    alcoliol,    96    por   cent, 
absolute  alcohol,  toluol,  and  Canada  balsam. 

The  sections  should  appear  yellowish,  wiili  a  trace 
of  red  to  the  naked  eye.  Microscopically,  the  cell 
nuclei  are  palo  brown,  the  protoplasm  yellowish,  the 
granules  red  (the  kind  of  red  varying  in  different  cells). 

(c)      ScIIRIDDE's    AZUIIE    II    -KOSIN-ACETONK    MlCTIIOD    FOK    StAINING 

Sections. — The  fixation  may  be  any  of  the  ordinary  methods,  e.g. 
formol-Miiller  (formalin  1  part,  Midler  9  parts).  Staining  with 
Giemsa  (2  drops  to  each  1  c.c.  of  distilled  water)  for  twenty 
minutes.  Careful  washing,  drying  with  blotting  paper,  and  then 
treatment  for  one  minute  in  pure  acid-free  acetone  (Kahlbaum). 

The  sections  are  then  passed  through  acid-free  xylol  or  toluol. 

They  are  then  mounted  in  Canada  balsam,  and  kept  in  the  dark. 

The  neutrophile  granules  are  violet-red,  the  eosinophile  granules 
red,  the  mast  cells  dark  blue,  the  erythrocytes  grass  green.  The 
myeloblasts  show  a  greyish-blue  protoplasm  without  any  granules. 

Besides  the  fuchsiuophile  granules,  some  of  the  lymphocytes 
possess  azurophile  granules,  whicli  can  be  rendered  visible  by 
means  of  Giemsa-Eomanowski's  staining.  These  granules  are 
met  with  exclusively  in  the  larger  cells.  They  are  at  times 
sparse  and  coarse  and  at  times  numerous,  fine  granules  of  a  bright 
red  colour.  Inequalities  and  fraying  of  the  contour  of  the  cells 
are  always  the  artificial  results  of  pressure,  and  many  of  the 
apparently  large  lymphocytes  in  the  smears  are  merely  the  results 
of  squeezing. 

The  protoplasm  possesses  no  affinity  to  the  neutral  and  acid 
dyes  save  in  the  case  of  the  larger  cells,  vrhen  the  affinity  is 
very  slight.  It  is  markedly  hasophile,  and  with  Giemsa  staining 
it  takes  on  a  pure  pale  blue  colour.  If  the  cells  have  been 
crushed  the  protoplasm  may  remain  unstained.  The  azure 
granules  then  appear  against  an  almost  white  background. 

Large  lymphocytes  occur  in  the  blood  of  children,  but  very 
rarely  in  the  blood  of  adults.  Very  large  elements  are  always 
pathological,  and  are  met  with  in  leukemia.  (Troje  erroneously 
called  them  "  marrow  cells  "  in  this  connection). 


94  ANiEMTA 

In  the  blood  of  adults  from  20  to  25  per  cent,  of  the  white 
blood  corpuscles  are  lymphocytes;  in  the  blood  of  children  the 
number  is  much  greater,  and  may  be  as  high  as  70  per  cent. 

An  increase  in  the  number  of  lymphocytes  is  not  frequently 
met  with.  When  it  occurs  it  is  spoken  of  as  lymphocytosis  or 
lymphaemia. 

2.  Large  Mononuclear  Leucocytes. — These  cells  are 
relatively  very  large,  being  usually  twice  or  three  times  the 
size  of  the  erythrocytes.  They  possess  a  fairly  large  oval 
nucleus,  which  stains  much  less  intensely  with  a  basic  dye  than 
the  nucleus  of  the  lymphocyte  does.  With  a  suitable  dye 
(hsematoxylin,  Giemsa)  they  reveal  a  very  delicate  slender  network 
of  chromatin.  The  nucleus  generally  shows  a  marked  tendency 
to  assume  a  polymorpho-nuclear  structure. 

The  protoplasm  is  very  broad,  possesses  a  close,  delicate 
basophile  reticulum,  which  is  extended  equally  right  up  to  the 
nucleus,  and  when  stained  by  Giemsa  takes  on  a  dusky  greyish- 
blue  (slate-grey)  colour.  In  the  meshes  an  extremely  fine  neutro- 
phile  granulation  is  seen  when  the  cells  are  properly  stained 
by  the  triacid  or  Giemsa  method.  This  granulation  is  distributed 
over  several  areas  of  the  cells,  but  not  uniformly  over  the  whole 
cell  (young,  beginning  granulation).  In  some  situations  the  fine 
granules  are  so  closely  packed  that  in  a  well-prepared  film 
some  of  the  edges  have  a  diffuse  pink  appearance  when  stained 
by  Giemsa  (see  Plate  II.). 

These  cells  are  quite  different  from  the  lymphocytes,  even  if 
the  neutrophile  granulation  is  not  taken  into  account.  They 
belong  to  the  "  transition "  forms,  which  will  be  described  later 
and  can  only  be  distinguished  from  the  latter  by  the  nucleus, 
which  scarcely  presents  any  polymorphous  character.  When 
they  are  really  well  stained  with  Giemsa  the  relationship  is  so 
clear  that  it  is  practically  impossible  to  divide  the  two  classes 
from  one  another  sharply. 

Large  and  crushed  lymphocytes  might  be  mistaken  for  these 
cells,  if  the  staining  is  too  pale  or  the  neutrophile  granulations 
are  not  sufficiently  coloured  to  be  distinguishable  as  such.     But 


THE   WIIITK   P>I/)()I)  (ORiniSCLKS      95 

scarcely  1  per  cent,  of  ccIIh  is  met  with  wliif-b  )iii<^lit  ))e  coiifuHed 
with  the  lar<i;e  leucocytes  in  normal  blood,  and  these  arc  without 
doubt  not  to  be  re^'arded  as  lymphocytes  from  a  genetic  ])oiiit  of 
view.  Tb;i,l/  this  is  so  is  shown  by  Mk;  fiict  tb;i,t  iiiifriiKidiiilc 
forms  do  not  exist,  (!V(in  under  p;i,tiiolo<^icii,l  comb'tioiis.  'i'hesf; 
cells  no  doubt  belong  to  the  myidoid  cell  group,  and  ar(;  in  all 
probability  formed  in  the  bone  marrow  out  of  myeloblasts. 

3,  The  Transition  Forms. — These  cells  possess  characteristics 
similar  to  the  preceding  form.  They  are  distinguished  from  tliem 
by  large,  often  irregular  hollowing  out  of  the  nucleus,  which 
may  lend  the  shape  of  a  wallet  to  it.  Another  point  of  difference 
lies  in  a  somewhat  greater  affinity  of  the  nucleus  to  the  nuclear 
dyes,  and  in  the  occurrence  of  more  plentiful  fine  neutrophile 
granulations  in  the  protoplasm  (Giemsa  or  triacid  staining). 
The  second  and  third  groups  together  represent  about  6  to  8 
per  cent,  of  all  the  white  blood  corpuscles. 

It  is  only  possible  to  distinguish  these  cells  accurately  when 
the  film  is  perfectly  stained  by  Giemsa's  method.  AVhen  this  has 
been  achieved  it  will  be  seen  that  azure  granules  are  never 
found  in  the  large  mononuclear  and  transition  forms,  and  that 
it  is  possible  to  distinguish  between  the  very  fine  neutrophile 
granulation  and  the  azure  granule  in  spite  of  a  certain  similarity 
in  the  tone  of  the  colours.  Eeal  difficulty  in  this  respect  only 
occurs  when  the  films  are  insufficiently  stained. 

4.  The  Polymorpho-nuclear  Neutrophile  Leucocytes. — 
These  cells  are  somewhat  smaller  than  the  two  forms  just 
described,  and  may  be  distinguished  by  the  following  characters. 
In  the  first  place,  they  possess  a  peculiar  polymorphous  nuclear 
form.  The  nuclear  mass  is  relatively  long  and  irregularly 
hollowed  out  and  constricted,  in  the  form  of  a  S,  Y,  E,  Z,  etc.  A 
complete  breaking  up  of  the  nucleus  into  three  or  four  small 
roundish  nuclei  can  take  place  during  life  as  a  pathological 
process.  Ehrlich  first  saw  this  in  a  case  of  hsemorrhagic  small- 
pox ;  and  it  is  seen  frequently  in  fresh  exudations.  Formerly 
the  breaking  up  of  the  nucleus  into  several  pieces  was  observed 
after  treatment  with  the  usual  reagents,  e.g.  acetic  acid,  and  for 


96  ANEMIA 

this  reason  Ehrlich  chose  the  term  "  poly  nuclear "  for  these 
cells,  although  it  must  be  admitted  that  this  does  not  actually 
fit  the  condition. 

The  nucleus  stains  well  with  all  the  nuclear  dyes;  the 
protoplasm  possesses  a  marked  attraction  for  the  majority  of 
the  acid  dyes,  and  is  obviously  characterised  by  the  presence  of  a 
close  neutrophile  granulation.  The  protoplasm  has  an  alkaline 
reaction,  which,  however,  is  less  marked  than  that  of  the  lympho- 
cytes. The  granulation  may  be  distinctly  seen  in  unstained  cells 
in  the  form  of  very  delicate  non-refractive  nodules. 

In  many  pathological  conditions,  especially  in  infective  pro- 
cesses and  suppuration,  iodophile  substance  can  be  recognised, 
more  especially  in  the  polymorpho-nuclear  neutrophile  leucocytes. 
Ehrlich  stained  films  after  drying  them  in  the  air  with  iodised 
rubber  solution  and  later  with  iodine  vapour.  Under  normal 
conditions  only  a  very  slight  brown  colorisation  in  the  neutro- 
phile cells  can  be  detected  when  this  technique  is  employed, 
although  in  pathological  specimens  a  very  intense  diffuse  or 
blotchy  reaction  may  be  obtained. 

If  fresh  blood  films  without  fixation  and  in  a  moist  state  be 
exposed  to  iodine  vapour,  as  recommended  by  Zollikofer,  all  the 
neutrophile  cells  without  exception,  even  under  normal  conditions, 
take  on  an  intense  brownish  staining  of  the  iodophile  granules. 

Save  when  Zollikofer's  vital  staining  is  employed,  these 
granules  obviously  dissociate  very  rapidly  under  normal  conditions, 
but  under  pathological  conditions  they  reveal  a  much  stronger 
cohesion. 

The  reaction  depends  on  a  substance  which  is  related  to  the 
amyloids,  and  not  on  a  glycogen. 

Neusser's  "  perinuclear  "  granules  are  not  preformed  elements, 
but  are  precipitates  of  the  stains. 

The  neutrophile  cells  contain  oxydising  ferments,  and  there- 
fore turn  guaiacum  tincture  blue,  a  reaction  which  is  never  met 
with  in  the  lymphocytes.  They  possess  in  addition  peptic  and 
autolytic  ferments.  This  was  first  discovered  in  autolysis,  and 
later  was  clearly  demonstrated  by  Stern,  as  well  as  by  Miiller 


THE  WTllTK  15LOOD  COllPUSCLKS      07 

and  JoclllUiUni,  who  sIhiVV(uI  iliat,  Uk;  ]ui]y\\\\(:\c:ii  cells  lii;ulc'  (U;f;p 
dells  ill  alljuminous  iiKMlin,.  Tli(!i(!  is  no  donhL  that  thoy  play 
a  very  important  ])iut  in  the  organism,  ((iiiLc  iipaiL  I'roni  tlie  well- 
known  phagocytosis. 

The  nutnbor  of  tlu;  nculiupliilo  cells  is  aljoul  iriOO  to  oOOO  [^er 
c.nim.,  i.e.  about  65  to  70  per  cent,  of  the  leucocytes. 

The  only  normal  site  of  production  of  these  cells  is  the  bone 
marrow. 

5.  The  Eosinophile  Cells. — These  cells  are  recognised  by 
a  coarse,  sliotty  granulation,  which  shows  considerable  avidity  for 
the  acid  dyes  and  resembles  in  other  respects  the  polynuclear 
neutrophiles. 

When  the  cells  are  lightly  stained  it  can  at  times  be  seen 
that  a  peripherally  placed  ring  of  eosinophile  grains  take  on  the 
dye  more  intensely  than  those  situated  in  the  interior  of  the 
cell.  The  nucleus  does  not  usually  stain  very  intensely,  and  is 
as  a  rule  less  lobulated  than  the  nucleus  of  the  polynuclear 
neutrophile  cells.  In  other  respects,  however,  the  nucleus 
closely  resembles  that  of  the  last-named  cell.  These  two  classes 
of  cell  have  one  property  in  common,  namely,  that  owing  to  a 
considerable  contractility  they  are  enabled  to  pass  through  the 
walls  of  the  vessels,  and  thus  into  exudations  and  pus.  The 
eosinophile  cells  are  usually  somewhat  larger  than  the 
neutrophiles. 

The  granules  in  an  unstained  condition  show  a  yellowish 
glossy  fat-like  appearance,  and  on  this  account  these  cells  can 
be  readily  distinguished  from  the  neutrophiles,  which  possess 
a  much  more  finely  granulated  and  not  glossy  appearance  in 
fresh  specimens.  About  2  to  4  per  cent,  of  the  white  blood 
corpuscles  are  eosinophile  cells,  which  means  that  there  are 
about  100  to  200  such  cells  in  each  cubic  millimetre  of  normal 
blood.  Their  site  of  origin  is  the  bone  marrow\  Under  normal 
conditions  an  extramedullary  genesis  cannot  be  accepted. 

The  view"  which  has  been  expressed  by  various  authors,  that 
the  acidophile  granules  originate  in  the  taking  up  of  haemoglobin, 
may  be  refused   altogether.     It   is  impossible   for  the   clinician 
7 


98  ■     ANEMIA 

to    reconcile    his    knowledge    of    the   eosinophile   cells   to    this 
view. 

Weidenreich's  method  of  proving  that  the  origin  of  the 
eosinophile  granules  is  to  be  sought  in  haemoglobin  is  highly 
unsatisfactory  and  has  been  disproved  by  Ascoli.  Kecently, 
Erich  Meyer  has  proved  conclusively  that  the  taking  up  of  red 
blood  corpuscles  by  macrophages  does  not  produce  any  eosinophile 
granules  (the  Meeting  of  German  Scientists  and  Physicians, 
Cologne,  1908).  Weidenreich's  views  have  thus  been  absolutely 
refuted.  But  apart  from  this,  the  assumption  that  acidophile 
granulations  took  place  from  a  pre-existing  structure  which 
possesses  a  basophile  reaction,  would  render  the.  genesis  of 
haemoglobin  inconceivable. 

6.  The  Mast  Cells. — These  cells  occur  in  normal  blood 
only  in  small  numbers;  they  seldom  reach  ^  per  cent.  Some 
healthy  persons,  however,  have  considerably  larger  numbers, 
without  any  ascertainable  cause. 

These  cells  are  rather  small.  Their  nucleus  is  peculiarly 
polymorphous,  and  is  either  shaped  like  a  clover  leaf  or  is 
quite  irregularly  lobulated.  It  takes  up  basic  dyes  with  but 
little  avidity. 

The  protoplasm  possesses  a  basophile  reticulum.  In  this 
reticulum  are  found  moderately  large,  very  basophile  granules, 
which  are  extremely  soluble  in  water  and  which  in  an  unstained 
condition  are  not  glossy.  They  have  a  marked  characteristic  in 
taking  on  a  metachromic  staining,  when  the  basic  dyes  are 
mixed  with  a  trace  of  azure.  For  example,  with  methylene-blue 
they  stain  violet.  This  metachromasia  is  well  marked  with 
thionin  and  with  cresyl-violet  E  (eatin,  of  the  Miihlheim  Dye 
Works).  In  this  last-named  mixture  the  granules  are  stained 
almost  pure  brown. 

The  staining  can  be  well  achieved  according  to  Jenner's 
directions,  since  the  methyl  alcohol  protects  the  granules  from 
solution.  Under  other  conditions  the  granules  dissolve  com- 
pletely or  partially  in  water,  and  the  most  weird  shapes  are 
left  behind.     If  they  are  not  completely  dissolved,  mere  traces 


TFIE  WHITE  lU.OOD  CORPUSCLES      00 

of  tlie  graiinldH  may  bi;  ret;uH(iil,  oi'  livcii  itulivi'liiul  grairiH. 
Wlien  aiaiiuMl  by  ({i(!iii,sa,  tlio  undissolved  granules  appear  mauve 
coloured,  aud  the  protoplasm  on  account  of  the  solution  of  the 
majority  of  the  granules  also  takes  on  this  coloui-. 

Tlie  normal  l'ornia,ti()n  of  IJh;  ])olyiii()rpho-iiiicl(;;i,i'  mast  cells 
wliicli  appear  in  the  blood  takes  place  in  the  bone  marrow. 
On  the  other  hand,  there  are  several  kinds  of  histogenic  mast 
cells  with  round  nuclei  in  the  tissues  which  have  quite  another 
genesis.  In  all  probability  these  two  kinds  of  mast  cells  have 
nothing  in  common. 

So  much  for  the  colourless  cells  which  arc  found  in  tlie  blood 
of  adults  under  normal  conditions. 


Pathological  Forms  of  White  Blood  Corpuscles. 

In  pathological  cases  the  forms  mentioned  above  may  be 
present  in  altered  numerical  proportions,  and  some  other  forms 
which  are  not  found  under  normal  condition  at  all  may  be 
observed.  Among  these  other  forms  the  following  are  the  most 
important : — 

1.  Mononuclear  Cells  with  Neutrophile  Granules 
("  myelocytes  "  of  Ehrlich). — These  cells  are  generally  very  large, 
and  possess  a  relatively  large  nucleus  which  stains  badly.  The 
nucleus  is  most  frequently  centrally  situated,  and  is  surrounded 
fairly  equally  with  protoplasm.  Apart  from  the  differences  in 
the  nuclei,  the  most  marked  difference  between  these  cells  and 
the  large  mononuclear  leucocytes  of  normal  blood  consists  in  the 
fact  that  the  protoplasm  of  the  former  contains  numerous  normal 
sized  (and  therefore  ripe)  and  very  easily  stained  neutrophile 
granules.  Beside  the  large  forms  of  myelocytes,  much  smaller 
forms  are  met  with,  the  size  of  which  does  not  differ  materially 
from  that  of  the  erythrocytes.  In  addition,  there  are  a  number 
of  grades  between  these  two  types. 

The  protoplasm  is  distinctly  but  not  excessively  basophilic. 
This  characteristic  decreases  as  the  cells  ripen.  It  also  shows 
a  fine  basophile  reticulum. 


100  ANiEMIA 

The  myelocytes  are  the  most  common  kind  of  cell  of  the 
normal  bone  marrow.  They  do  not  occur  physiologically  in  any 
other  situation.  They  are  generally  regarded  as  the  precursors 
of  the  polynuclear  neutrophile  blood  leucocytes. 

Myelocytes  only  leave  their  physiological  abode  under  morbid 
conditions.^  This  is  especially  marked  when  the  medulla  is 
affected  by  an  abnormal  hypertrophic  process  (as  in  leukaemia) 
or  when  it  works  at  high  pressure,  as  in  many  forms  of  leuco- 
cytosis  {e..g.,  in  pneumonia,  variola,  post-hanuorrhagic  aneemia). 

Myelocytes  may  be  observed  as  a  common  find  when 
malignant  tumours,  and  especially  carcinomata,  are  growing  in 
the  bone  marrow,  and  intense  signs  of  irritation,  probably  of  a 
toxic  nature,  appear  in  the  neighbourhood  of  the  tumour  nodules. 
Neutrophile  myelocytes  are  found  in  the  blood,  even  when  there 
is  no  leucocytosis  in  severe  functional  disturbances  of  the  bone 
marrow,  e.g.  in  severe  anaemias — Biermer's  anaemia — in  intoxica- 
tions, and  in  infections.  In  these  conditions  the  medulla  has 
obviously  lost  the  power  of  preventing  unripe  cells  from  passing 
over  into  the  circulation. 

The  blood  in  myeloid  leukaemia  is  characterised  by  a  high 
proportion  of  myelocytes.  A  large  number  of  these  cells  may 
also  be  met  with  in  the  blood  in  carcinoma  of  the  bone  marrow, 
and  during  convalescence  from  acute  infective  diseases,  e.g. 
croupous  pneumonia. 

2.  Eosinophile  Myelocytes. — These  cells  may  be  regarded 
as  the  analogies  of  the  neutrophile  cells,  and  are  often  found  in 
considerable  numbers  in  myeloid  leukaemia.  They  are  only  rarely 
present  in  other  conditions,  but  may  be  found  in  marked  eosino- 
philia,  such  as  in  trichinosis  and  scarlatina,  while  single  cells  may 
be  seen  in  severe  forms  of  anaemia. 

Their  significance  and  the  causes  which  impel  them  to  pass 

^  The  view  ■which  "Weidenreich  has  recently  revived,  that  myelocytes  occur  in 
the  blood  of  normal  adults,  is  quite  erroneous  {Arch.  f.  Mikros.  Anat.,  1908,  vol. 
Ixxii.),  ami  is  actually  disproved  by  Weidenreich'g  own  diagrams.  In  these 
diagrams  the  cells  supposed  to  be  myelocytes  are  without  doubt  the  ordinary 
large  mononuclear  leucocytes  of  Ehrlich.  Weidenreich  therefore  does  not  even 
know  the  normal  cells  of  human  blood  ! 


THE  WHITE  HLOOI)  CORIMJSCLES     loi 

into  tli(!  (;ii'cii];i,lyi<)ii  ;m'(!  the  siuik;  a.s  iJiosc,  ;i'|)i)lyiii;^'  Lo  Uia  rjLlicr 
forms  of  myelocytes.  Homo  of  the  gninuloH  aie  very  frequently 
deep  blue  when  stained  by  (liemsa,  and  not  red  or  reddish 
brown.  Occasionally  ;ill  the  granules  show  this  has(jphile  pre- 
ceding sta,(i;o  in  hiukicniia. 

3.  Mast  Myelocytes. — These  are  also  analogies  of  thf; 
ordinary  myelocytes.  They  may  Ijc  present  in  the  blood  of 
myeloid  leuktemia,  either  as  small  or  as  large  cells.  Some  of 
the  granules  are  i'rc([uently  l)lue  when  stained  with  Giemsa  and 
not  mauve.  Occasionally  all  the  granules  take  on  this  blue 
colour,  since  the  mauve  granulation  develops  from  a  more 
markedly  basophile  blue  young  form  of  granulation.  The  young 
mast  cell  granules  differ  from  the  older  granules  strikingly  jjy 
their  far  greater  insolubility  in  water. 

4.  Myeloblasts  (Naegeli). — These  cells  are  the  precursors 
of  the  myelocytes,  and  contain  absolutely  no  granules.  They 
are  the  least  diiierentiated  cells  of  myeloid  tissue,  and  are  there- 
fore very  numerous  in  the  embryonal  tissues.  ^lyeloblasts  are 
only  sparsely  present  in-  the  bone  marrow  of  adults,  but  in 
certain  diseases  they  may  predominate, — for  example,  in  Biermer's 
ansemia,  in  other  severe  ana?mias,  and  in  enteric  fever.  But 
they  are  especially  numerous  in  leukaemia,  and  in  the  stages  just 
preceding  death  in  chronic  myeh"emia  they  may  predominate 
among  all  the  cells  of  the  blood.  The  same  applies  also  with 
regard  to  acute  myeloid  leukiemia,  so  that  a  true  myeloblastic 
leukemia  may  be  said  to  exist.  All  undoubted  cases  of  acute 
myelremia  reveal  this  characteristic  appearance  of  the  blood, 
which  may  be  regarded  as  the  expression  of  such  an  enormous 
pathological  proliferation  that  only  unripe,  little  differentiated 
cells  are  formed. 

The  myeloblasts  may  occiir  in  large  or  small  forms.  The 
former  can  only  be  distinguished  from  myelocytes  by  the  absence 
of  granules. 

The  nucleus  of  the  myeloblast  is  relatively  large,  is  roundish 
or  oval  in  shape,  and  shows  a  delicate  structure.  It  stains  fairly 
intensely  with  the  nuclear  stains, — at  all  events  much  better  than 


102  ANJEMIA 

the  nuclei  of  the  large  pathological  lymphocytes.  With  pyronin- 
methyl-green  staining  and  also  with  properly  managed  G-iemsa, 
it  can  be  demonstrated  that  there  are  almost  always  several 
nucleoli  present ;  as  a  rule  there  are  three  or  four,  while  at 
times  there  are  more.  With  Giemsa  the  nucleoli  stain  blue, 
and  are  therefore  easy  to  recognise  and  to  distinguish  from 
collections  of  chromatin.  In  chronic  myeloid  leukaemia  these 
nucleoli  may  be  seen  very  distinctly  as  blue  rings  in  the  nuclei 
when  stained  by  Giemsa,  while  in  the  ripe  myelocytes  nothing 
of  this  nature  can  be  detected. 

The  protoplasm  is  reticular  and  definitely  basophile.  The 
network  is  continued  right  up  to  the  nucleus  without  any  inter- 
position of  a  free  areola.  There  are  no  azurophile  or  fuchsino- 
phile  granules  of  Schridde.  As  a  rule,  however,  cells  are  met 
with  which  are  otherwise  similar  in  every  respect  to  the  regular 
myeloblasts  without  granulation  but  which  show  beginning  neutro- 
phile  granulation.  These  are  the  intermediary  forms  between 
the  myeloblasts  and  myelocytes.  The  well-marked  basophile 
character  of  the  protoplasmic  reticisium  decreases  and  the 
nucleoli  disappear  as  the  fine  neutrophile  granulation  increases. 
These  intermediate  forms  may  be  distinguished  from  the  large 
mononuclears  and  transition  forms  by  their  round  or  oval  nucleus 
with  nucleoli,  and  by  the  fact  that  the  reticulum  of  the  protoplasm 
stains  blue  rather  than  greyish  blue. 

Myeloblasts  are  always  met  with  in  myeloid  formation  out- 
side the  bone  marrow,  and  especially  in  embryonal  livers.  They 
can  be  readily  demonstrated  in  sections  by  means  of  Schridde's 
or  Fischer's  staining  methods,  and  their  characteristics  can  be 
recognised  as  contrasted  with  the  lymphocytes. 

The  fact  that  these  cells  cannot  possibly  be  lymphocytes  is 
proved  by  the  complete  absence  of  fuchsinophile  granules,  and 
especially  by  their  relationship  to  myeloid  formation.  Apart 
from  this,  it  must  be  recognised  that,  histologically  and  histo- 
genetically,  they  are  the  direct  antithesis  of  the  cells  of  lymphatic 
tissue. 

It  will    thus    be  seen  that  these    cells    must    be    separated 


THE   WIIITK  JJLOOI)  CORPUSCLKS      10.} 

coiiipletGly  from  IIk;  Iyiiii)liocylf3H  on  hioloj^ical  groundK. 
Myeloblasts  only  occur  in  the  blood  and  tissues  in  severe 
disturbances  of*  the  myeloid  system,  and  are  then  accompanied 
by  myelocytes  and  their  descendants ;  they  aie  fuitlier  often 
associated  with  nucleated  red  blood  corpuscles.  In  severe 
lesions,  or  when  there  is  rapid  proliferation  of  the  medullary 
tissue,  they  pass  over  into  the  circulation  in  steadily  increasing 
numbers.  Under  these  conditions  the  foinis  iiiterniediato 
between  these  cells  and  the  myelocytes  are  met  with  regularly 
in  large  numbers. 

Morawitz  and  Eehn  have  produced  experimental  evidence  to 
prove  that  the  myeloblasts  are  the  most  indifferent  cells  in  the 
medullary  tissue.  They  were  able  to  produce  artificially  an 
aplastic  antemia  by  repeated  large  bleedings,  until  the  red 
medulla  became  absolutely  incapable  of  producing  any  moie 
erythrocytes  and  the  leucocyte  formation  was  limited  almost 
entirely  to  non-granulated  myeloblasts. 

The  myeloblasts  are  distinguished  from  the  atypical  patho- 
logical large  lymphocytes  by  the  absence  of  a  fuchsinophile 
perinuclear  zone  of  granules,  by  the  more  intense  triacid  staining 
of  the  nucleus,  and  by  the  network  of  basophile  protoplasm, 
which  reaches  right  up  to  the  nucleus. 

Even  if  it  must  be  admitted  that  it  may  be  difficult  in  some 
instances  to  recognise  the  myeloblasts  with  certainty,  or  even 
impossible  wdien  the  differential  staining  is  not  sufficiently  distinct, 
there  can  be  no  possible  doubt  that  non-granulated  cells  of  the 
myeloid  system  actually  exist,  which  have  nothing  whatsoever  to 
do  with  lymphocytes.  This  has  been  definitely  proved  by  the 
histology  of  the  hcemopoietic  organs,  by  the  study  of  the 
developmental  conditions,  and  by  the  biological  behaviour  of  the 
cells  themselves. 

The  myeloblasts,  considered  from  a  theoretical  point  of  view, 
are  of  very  considerable  importance.  If  they  were  identical 
with  lymphocytes  the  chief  support  on  which  Ehrlich  built 
up  his  classification  of  the  leucocytes  would  fall  to  the  ground. 
It  would  be  impossible  to  support  in  principle  a  division  of  the 


104  i^NJEMIA 

two  leucocyte-forming  organs  and  the  cells  which  these  organs 
produce,  i.e.  the  dualistic  view. 

It  is  not  .surprising  that  the  opponents  of  Ehrlich's  doctrine 
refuse  to  recognise  the  myeloblasts.  If  this  were  sound  this 
chapter  of  lipematology  would  return  to  the  chaos  in  which  it 
was  formerly  placed,  and  the  leucocytes  would  represent  various 
phases  of  one  kind  of  cell. 

Embryology,  morphology,  histology,  and  biology,  however, 
demand  a  sharp  dualistic  division  in  no  uncertain  voice,  and 
assert  on  principle  the  difference  between  the  myeloblasts  and 
the  lymphocytes. 

The  large  mononuclear  cells  and  the  transition  forms  of  the 
blood  are  not  myeloblasts,  and  can  be  distinguished  from  these 
cells  by  their  totally  different  nuclei,  in  which  no  nucleoli  are 
demonstrable  by  means  of  Giemsa's  staining,  and  by  their 
neutrophile  granulation ;  but  it  must  be  recognised  that  these 
normal  cells  of  the  blood  are  derivatives  of  the  myeloblasts. 

5.  Stimulation  Forms  (Tlirk)  =  Pathological  Myeloblasts 
(Schridde,  Naegeli). 

Under  pathological  conditions,  especially  in  inflammatory 
leucocytosis,  and  also  in  ansemia,  tiimours,  etc.,  the  blood  may 
contain  cells  which  are  characterised  by  a  highly  basophilic 
protoplasm  (deep  blue  when  stained  by  Giemsa ;  bright  red  with 
pyronin-methyl  green ;  dark  reddish  brown  with  triacid). 

These  cells  are  usually  large,  and  may  be  very  large, 
although  small  examples  do  occur. 

The  nuclei  are  round  or  oval,  take  on  the  stain  intensely,  and 
in  structure  look  exactly  like  the  nuclei  of  myelocytes  and  not 
of  lymphocytes.  The  autlior  has  never  met  with  nucleoli.  A 
radiating  structure  of  the  nuclei  is  not  present.  The  nuclei 
usually  lie  excentrically  placed.  The  protoplasm  is  markedly 
basophilic,  and  often  shows  well-marked  vacuolisation. 

These  cells  have  no  connection  with  the  true  lymphocytic 
plasma  cells,  in  spite  of  the  views  which  were  formerly  held. 
That  this  is  so  is  proved  by  the  absence  of  a  radial  nuclear 
structure,  a   perinuclear  zone,  and  fuchsinophile    granules.      At 


THE  WHITE  BLOOD  CORPUSCLES     105 

first  sight  the  two  colls  ii])l)<!!ir  to  ho  very  similar,  oi»  aooomit  of 
the  well-iiiarlvod  ])iiso]»liilio  charaotor  nud  tho  prosfnico  of 
vacuoles  in  tho  prot()i)ln,siii.  It  was  iormorly  h(il«l  tiiat  they 
were  related  to  the  nucleated  rod  colls,  hut  this  is  ooitainly 
incorrect.  On  the  contrary,  it  must  he  rccogiiisod  that  those 
cells  are  pathological  myclohlasts.  Their  connection  with  tho 
myeloid  system,  which  can  ht;  shown  morphologically,  suggests 
this,  and  the  view  receives  further  support  hy  a  study  of  the 
biological  behaviour  of  the  cells.  They  occur  as  a  rule 
together  with  myelocytes,  especially  in  leucocytosis,  as  in 
croupous  pneumonia.  They  are  not  infrequently  mot  with  m 
small  numbers  in  other  conditions. 

6.  Pathological  Lymphocytes. — In  lymphatic  Iculaomia 
and  especially  in  the  acute  forms,  peculiar  cells  pass  into  the 
blood,  which  of  necessity  must  be  regarded  as  pathological 
since  they  have  no  physiological  analogies. 

They  resemble  the  large  lymphocytes,  often  showmg  a  wide 
protoplasmic  band,  with  all  the  characteristics  of  lymphocytes. 
On  the  other  hand,  azure  granules  are  but  rarely  present,  and 
may  be  entirely  absent.  The  protoplasmic  reticulum  and  the  peri- 
nuclear zone,  however,  are  particularly  prominent. 

The  nucleus  is  poor  in  chromatin,  and  therefore  takes  up 
the  stain  badly,  so  that  ordinary  triacid  staining  is  insufficient. 
The  staining  is  best  carried  out  with  Giemsa.  The  author  has 
come  across  one  or  two  nucleoli  in  the  nuclei  in  all  his  speci- 
mens.    Azurophilic  granules  are  frequently  met  with. 

Beside  possessing  the  characteristic  of  occurring  as  giant 
cells,  there  is  a  tendency  of  the  nucleus  to  form  a  peculiar 
coarse  hollowing  out  and  lobulation,  so  that  actual  polymorphous 
nuclei  result.  The  nuclei,  however,  have  no  similarity  to  the 
slender,  drawn-out  nuclei  of  the  leucocytes.  These  forms  are 
usually  termed  "  Eieder's  forms  "  (see  Fig.  4,  p.'  88). 

The  origin  of  these  cells  is  placed  in  the  lymphatic  system,  as 
has  been  shown  by  histological  study  of  the  organs.  The  fact 
that  those  forms,  lying  intermediate  between  the  myeloblasts 
and    the    myelocytes    which    are    so    frequently    met   with    in 


106  ANtEMIA 

myeloblastic  leukaemia,  are  never  found  in  these  organs  speaks 
against  a  possible  connection  of  these  cells  to  the  myeloblasts. 
The  pathological  lymphocytes  may  be  observed  in  ordinary 
lymphatic  leukaemia  of  many  years'  standing,  albeit  in  small 
numbers.  There  are  further  types  of  leukaemia  in  which  the 
small  lymphocytes  are  at  first  increased  in  number,  and  later 
these  cells  become  larger  until  the  pathological  forms  are  seen. 
Under  the  effect  of  sepsis  and  other  factors,  the  predominating 
large  forms  and  Eieder's  cells  may  disappear  again,  and  practic- 
ally only  small  cells  remain  (see  Fabian,  Naegeli,  Schatiloff). 
The  changes  connected  with  these  cells  are  extraordinarily  great. 

The  form  dealt  with  in  this  section  is  present  almost  exclus- 
ively in  lymphatic  leukaemia  and  lymphocytomata. 

7.  Plasma  Cells. — These  cells  are  extremely  rare  con- 
stituents of  the  circulating  blood.  They  may  occur  in  plasma- 
cell  leukaemia  (Gluzinski  and  Eeichenstein  and  the  author),  in 
plasma-cell  myelomata  (Aschoff-Schridde),  and  as  curiosities  or 
single  types,  e.g.  in  mastitis  and  lymphatic  leukaemia  (Naegeli). 
They  are  characterised  by  a  radiating  nucleus  which  is  rich  in 
chromatin,  and  as  a  rule  excentrically  placed,  and  which  con- 
tains one  or  two  nucleoli,  by  a  prominent  perinuclear  zone,  by 
the  existence  of  protoplasm,  which  is  extremely  basophilic  and 
which  shows  large  vacuoles,  and  lastly  by  the  presence  of 
Schridde-Altmann's  fuchsinophile  granules. 

Plasma  cells  are  very  commonly  met  with  in  the  tissues.  In 
this  situation  they  exist  either  as  small  lymphocytic  cells  with 
dark  radiating  nuclei,  or  as  large  lymphoblastic  cells  with  pale 
nuclei,  which  do  not  show  distinct  radial  structure. 

The  origin  of  the  plasma  cells  is  no  longer  uncertain.  They 
are  pathological  descendants  of  the  lymphocytes.  This  is  proved 
by  the  presence  of  Schridde's  fuchsinophile  granules.  In  the 
earlier  definitions  Unna  did  not  limit  the  use  of  the  term 
plasma  cell  nearly  as  sharply  as  it  is  now  limited ;  he  in- 
cluded all  those  cells  which  gave  the  so-called  plasma  reaction, 
i.e.  which  showed  an  intensely  basophilic  protoplasm.  This 
criterium   does   not    suffice   the   present   needs,   since   it   would 


THE  WIIITK   IJLOOI)  (OIMMJSCLKS      107 

include  colls  of  a  very  vuriod  ())'i<j,iii  .-uid  (ivcii  yoiiii;^-  cfjimcclivc- 
tissue  colls. 

Plasma  cells,  as  thoy  are  regarded  at  ])reReni,  are  well 
characterised  cells  which  are  exclusively  derived  finm  lymphatic 
elements. 

It  is  unnecessary  to  discuss  in  this  place  the  importance  which 
these  cells  possess  for  the  various  tissues  of  the  body. 

It  must  not  1)0  supposed  that  the  foregoing  is  a  complete  list 
of  the  abnormal  forms  of  the  white  blood  corpuscles.  There  is  no 
need  to  deal  specially  with  variations  of  the  size  of  the  cells, 
which  affect  the  polynuclears  and  the  eosinopliiles  chiefly,  and 
which  lead  to  the  formation  of  dwarf  and  giant  forms.  J^^ven 
when  the  difference  in  size  is  very  considerable  these  cells  always 
possess  sufficiently  marked  characteristics  to  enable  the  observer 
to  recognise  them  as  cells  of  the  given  type. 

In  addition  to  the  forms  mentioned,  there  are  cells  which 
contain  granules  possessing  absolute  or  partial  basophile  characters. 
This  occurs  more  especially  in  the  eosinophile  myelocytes  with 
mixed  acidophile  and  unripe  basophile  granulation,  but  which 
in  contrast  to  the  mast  cells  do  not  show  any  metachromic 
granulation.     Such  cells  are  frequently  met  wdth  in  leukremia. 

At  times  the  individual  granules  of  the  neutrophile  leuco- 
cytes reveal  w^eak  basophilic  characters,  in  the  form  of  basophile 
young  forms. 

Pathological  changes  can  be  recognised  in  the  development  of 
neutrophile  leucocytes,  especially  in  severe  infective  processes, 
when  the  granulation  of  the  protoplasm  is  either  absent  or  very 
badly  developed,  while  the  nucleus  is  well  formed  and  shows  the 
type  of  a  slender  polymorphous  formation. 

Abnormal  appearances  of  the  nuclei  are  met  with  still  more 
frequently  in  infective  diseases.  In  these  cases  the  lobulation 
of  the  nucleus  is  less  well  marked  than  in  the  cells  of  normal 
blood.  Arueth  has  studied  these  variations  very  minutely  and 
believes  that  they  are  young  elements,  because  the  polymorpho- 
nuclear cells  are  derived  from  the  round  nucleated  myelocytes. 
He    divided    the    neutrophiles    into    classes   according    to    the 


108  ANJEMIA 

number  of  segments  of  the  nucleus,  and  termed  the  condition, 
when  the  segments  were  less  numerous  than  normal,  as  a 
"  sinistral  asymmetry."  ^  Arneth's  conclusions  are  very  far 
reaching,  not  only  with  regard  to  diagnosis  but  also  with  regard 
to  prognosis,  treatment,  and  some  aspects  of  the  doctrine  of 
immunity.  Up  to  the  present,  both  confirmatory  and  adverse 
criticisms  have  been  expressed.  Arneth  attempted  to  disprove 
the  latter,  some  of  which,  it  must  be  admitted,  are  very  weak. 

In  the  first  place,  it  must  be  admitted  that  the  young 
elements  show  indistinct  lobulation  of  the  nucleus,  and  that  it 
is  extremely  difficult  to  classify  them :  two  competent  observers 
may  differ  as  to  the  number  of  segments.  The  more  marked  the 
nuclear  staining  is,  the  greater  will  be  the  difficulty  in  dividing 
them  into  individual  classes.  The  author  has  often  been  unable 
to  arrive  at  any  definite  conclusion  in  a  large  percentage  of 
cells,  especially  when  he  has  employed  G-iemsa  staining. 

Quite  apart  from  the  fact  that  some  observers  have  included 
large  mononuclears  and  transition  forms  in  the  first  and  second 
classes,  actual  difficulties  in  the  determinations  arise  for  the 
following  reasons.         ' 

In  the  first  place,  for  example,  bisegmented  nuclear  forms 
may  be  closely  connected  with  myelocytes,  as  Arneth  supposes, 
but  in  the  case  of  more  segments  being  present  in  the  nuclei  it 
is  difficult  to  prove  such  a  regular  stage  series  in  the  development 
as  Arneth's  classification  assumes.  In  the  next  place,  there  are 
undoubtedly  other  possibilities  which  might  produce  an  apparent 
simplification  of  the  lobulation  of  the  nuclei.  It  is  by  no  means 
uncommon  for  pathological  leucocytes  to  appear  in  the  blood, 
possessing  but  slightly  lobulated  nuclei,  which  do  not  belong  to 
the  early  stages  of  the  developmental  series.  The  segment  in 
these  cases  are  small  and  stain  darkly,  are  blotchy  or  swollen, 
and  do  not  possess  the  delicate  lightly  stained  chromatin  network 
of  young  elements. 

'  Tlie  term  "  Verscliiebuiig  uach  links"  has  not  yet,  as  far  as  the  translator  is 
aware,  been  translated  into  English.  After  consultation  with  hsematologists  and 
mathematicians,  the  term  "sinistral  asymmetry"  has  been  decided  upon. 


THE  VVniTE  BLOOD  CORIMJSCEKS     100 

Evoii  il'  ihoro  aro  many  ])OKsil)ilili(!K  wutUir  which  iiiiporfectly 
lobulatcd  t'oniis  of  iiiiohu  occui',  it  must.  Ito  achuitted  that  thf; 
occurreiico  ol'  siuih  (-(jlls  \h  jihiKuiiuil  ;iii(l  therefore  worthy  of 
notico.  T]i(!  aiilhor,  howcvcM',  docs  iiol,  fed  jiistilicr]  in  j^oinp 
nearly  as  Far  .'is  Ai-noth  does  in  his  dcihictions,  csiJCfMully  becaiiso 
the  methods  of  examination  are  not  very  reliable. 


II. —ON  THE  SITE  OF  ORIGIN  OF  THE  WHITE  BLOOD 
CORPUSCLES. 

It  is  of  the  utmost  importance,  for  the  purpose  of  gaining  a 
clear  insight  into  blood  histology,  that  exact  impressions  should 
be  gained  with  regard  to  the  formation  of  the  blood.  It  is 
necessary  to  inquire  whether  and  in  what  degree  the  three 
systems :  the  lymphatic  glands,  the  bone  marrow,  and  the  spleen, 
all  of  which  undoubtedly  are  intimately  associated  with  the 
blood,  participate  in  its  formation. 

The  most  direct  method  of  deciding  this  question  experi- 
mentally, i.e.  by  eliminating  the  organ  concerned,  is  unfortunately 
only  applicable  in  the  case  of  the  spleen.  The  importance  of  the 
lymphatic  glands  and  the  bone  marrow,  which  cannot  be  eliminated 
in  toto,  must  therefore  be  estimated  by  histological  and  clinical 
investigation.  It  is,  however,  only  possible  to  gain  a  clear  insight 
into  this  and  similar,  equally  important  questions  by  combin- 
ing animal  experiment,  histological  examination,  and  especially 
clinical  biological  observation,  and  carefully  registering  the  results 
in  a  large  number  of  cases.  It  cannot  be  too  strongly  urged 
that  it  is  essential  that  every  one  who  wishes  to  carry  out 
hfematological  researches  should  first  gain  a  general  experience 
by  examining  a  large  number  of  specimens,  so  that  mistakes  may 
be  avoided.  In  many  instances  an  attempt  has  been  made  to 
cover  a  want  of  experience  by  substituting  a  careful  study  of  the 
literature ;  but  the  histology  of  the  blood  has  not  been  advanced 
thereby  in  the  least.  A  characteristic  of  this  kind  of  work  is 
found  in  the  habit  of  drawing  far-reaching  conclusions  involving 
the   whole    pathology  of   the  blood  from  the   examination  of   a 


no  ANiEMIA 

single  case  or  from  one  independent  observation.  An  example  of 
this  may  be  quoted  in  Troje's  publication  of  the  details  of  a 
ease  in  which  he  did  not  recognise  the  lymphatic  character  of 
the  leukemia,  and  on  this  account  regarded  it  as  an  example  of 
myelogenous  leukaemia,  thereby  rendering  everything  that  had 
been  previously  established  with  regard  to  this  subject  nugatory 
and  turning  it  all  upside  down.  Another  instance  was  the 
definition  of  the  term  hyaline  medullary  cell  solely  on  the  basis 
of  the  finds  in  bone  m.arrow  smears,  from  which  it  was  con- 
sidered that  these  cells  are  the  precursors  of  all  red  and  white 
corpuscles  (Grawitz).  This  form  of  medullary  cell  is  never 
found  in  sections.  It  is  merely  an  artificial  appearance,  crushed 
myeloblasts,  the  basophilic  nature  of  the  protoplasm  of  which  has 
been  lost  in  the  crushing.  Further,  it  is  just  as  difficult  to 
avoid  falling  into  error  when  conclusions  are  based  entirely  on 
animal  experiment  without  any  controlling  by  clinical  experience, 
as  has  been  done  in  numerous  articles  by  Uskoff.  The 
clinician  rather  than  the  anatomist  or  the  physiologist  is 
capable  of  offering  information  on  these  matters. 

It  is  true  that  the  development  of  granule  staining  in 
sections  has  gone  so  far  that  embryology  and  minute  histology  as 
well  as  biological  clinical  studies  are  capable  of  revealing  valuable 
information.  In  the  combination  of  all  these  branches  of  in- 
vestigation, and  in  the  supplementing  of  one  method  of  research 
by  another,  the  majority  of  the  questions  are  being  explained 
at  present.  The  "peripheral"  hsematologist  has  no  longer  any 
justification  for  his  existence. 

It  is  always  absolutely  necessary  to  supplement  clinical 
investigation  by  embryology  and  histology  for  advance  in  histo- 
genetic  problems.  Many  points  have  been  clearly  settled  in  this 
way,  and  the  science  of  hasmatology  is  certainly  approaching 
some  definite  final  conclusions. 

It  will  therefore  be  realised  that  the  views  of  some  authors 
have  become  unworthy  of  being  taken  into  consideration  when 
their  studies  have  been  limited  to  the  peripheral  blood  and 
possibly  smear  preparations  from  the  organs. 


THE  WHITE  lU.OOD  CORPUSCLES     111 

(re)  The  Spleen. 

The  question  whether  th(!  s]il(;(!ii  pirxhiccs  while  l^luod 
corpuscles  has  been  a  liiiniiiii;-  one  .siiiec  !,li(;  c;!,!-]/  days  of 
hceinatology. 

Attempts  were  Ih'st  made  to  jnove  th(3  participation  of  tlie 
spleen  in  the  formation  of  the  white  blood  corpuscles  by  counting 
these  cells  in  the  afferent  and  efferent  vessels  of  the  s])leen.  It 
was  even  suggested  that  the  increase  of  cells  in  the  vein  as 
compared  with  the  artery  could  be  accepted  as  proof  of  the 
blood-forming  power  of  the  spleen.  The  results  of  these 
countings,  however,  are  extremely  variable,  and  wliile  some 
observers  found  an  increase  in  the  veins,  others  found  the  reverse. 
It  is  now  realised  that  such  a  coarse  method  of  attacking  the 
problem  is  of  no  practical  value. 

Certain  facts  have  been  brought  to  light  by  recent  researches. 
It  has  been  found  that,  after  removal  of  the  spleen,  some  of  the 
lymphatic  glands  become  more  fully  developed,  while  the  changes 
of  the  thyroid  gland,  which  have  been  observed  by  some 
investigators,  cannot  be  regarded  as  constant. 

Attention  must  further  be  called  to  the  blood  observations 
which  Mosler,  Eobin,  Winogradow,  Zesas,  Staehelin,  and  others 
carried  out  with  animals  and  human  beings  from  whom  the 
spleen  had  been  removed.  These  experiments  show  that  after 
the  lapse  of  a  considerable  time  a  definite  leucocytosis  occurs. 
Professor  Kurloff  carried  out  some  exhaustive  experiments  in 
Ehrlich's  laboratory  in  1888,  by  means  of  which  he  was  able  to 
study  the  behaviour  of  the  blood  after  removal  of  the  spleen. 

These  experiments  have  been  minutely  described  in  the  first 
edition  of  this  work,  and  will  therefore  only  be  sketched  in 
outline  in  this  place. 

The  blood  of  a  normal  guinea-pig  contains : — 

1.  Polymorpho-nuclear  leucocytes  with  pseudo-eosinophile 
granulation,  functionally  analogous  to  the  neutrophiles  of  the 
human  subject,  40  to  50  per  cent.  They  are  derived  from  the 
bone  marrow. 


112 


AN.EMIA 


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2.  Polymorpho- 
nuclear eosino- 
phile  cells,  about 
1  per  cent. 

3.  Mgrosino- 
phile  cells,  anal- 
ogous  to  the 
eosinophile  cells, 
but  the  granules 
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mixture  in  pre- 
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red.  They  take 
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triacid. 

4.  Cells  with 
vacuoles,  15  to  20 
per  cent. 

5.  Lympho- 
cytes, 30  to  35 
per  cent. 


Kurloff,  in  his 
extremely  careful 
and  laborious  ex- 
aminations, deter- 
mined the  total 
S  "f  .  number  of  leuco- 
g  §  =9  cytes  and  then  the 
percentages  of  the 
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pseudo-eosinophile, 
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TIIK   WIIITK   IJLOOI)  COIIJMISCLKS     11.'} 

ated  cells,  as  well  as  of  the  lynipliocytos.  llo  was  tliiis  ahlr;  to  prove 
that  in  xiiiconiplicated  cases  of  icinoval  of  ilic.  s])I(!(;n,  in  which  all 
inflammatory  processes  wliich  involvi;  an  imiciisc  of  iJic  ])ol_ynuclcar 
noutrophilo  corpnscles  were  cxcJiiilctl,  a  gradual  increase  limited  to  the 
lymphocytes  up  to  twice  or  three  times  the  original  value  is  noticed, 
while  the  numhers  of  all  the  other  elements  remain  ahsolutely  unulterefl. 

The  increase  in  the  nunil)er  of  lyinphocytos  occurs  (Ini'in^r  the 
course  of  the  first  year  after  the  removal  of  the  spleen.  This 
increase  must  be  regarded  as  the  expression  of  a  hy][)erplasia  of 
the  lymphatic  glands,  and  especially  of  the  mesenteric  glands. 
The  loss  of  the  splenic  function  is  thus  in  part  compensated  by 
the  lymphatic  system. 

The  pseudo-eosinophile  cells  show  a  temporary  increase  after 
the  operation,  but  no  marked  variations  have  been  noticed  in  the 
transition  forms. 

In  the  second  year  after  the  operation  a  very  considerable 
increase  in  the  number  of  eosinophiles  is  constantly  observed. 

Kurloff's  experiments  thus  prove  that  the  spleen  of  the 
guinea-pig  only  plays  a  minor  part  in  the  formation  of  white 
blood  corpuscles,  and  that  after  splenectomy,  compensatory 
functions  are  assumed  during  the  first  year  by  the  lymphatic 
glands.  In  the  second  year  a  considerable  increase  of  the  eosino- 
phile  cells  takes  place.  It  is  necessary  again  to  point  out  that 
the  spleen  has  nothing  to  do  with  the  formation  of  the  pseudo- 
eosinophile  polynuclear  cells,  wdiich  are  the  analogies  of  the 
polynuclear  neutrophile  cells  of  human  beings. 

It  is  necessary  in  the  next  place  to  inquire  how  observations 
on  human  beings  compare  with  Kurloff's  observations,  which 
after  all  might  be  regarded  as  peculiarities  of  the  species'  of 
animal. 

Absolutely  analogous  conditions  can  be  found  in  those  cases 
of  healthy  persons  who,  as  the  result  of  trauma,  have  been  sub- 
jected to  splenectomy.  Unfortunately,  such  cases  are  extremely 
rare,  but  it  would  be  of  great  value  if  the  changes  in  the  blood 
could  be  studied  systematically  for  several  years  in  such  cases. 
The   observations  made  up    to   the  present  have  led  to    the 


114  ANEMIA 

following  results.  A  lymphocytosis  lias  been  observed  after  the 
operation,  which  at  times  was  of  considerable  duration  and  at 
times  merely  temporary.  In  the  latter  case  the  increase  was 
probably  only  an  after-effect  of  the  operation,  and  corresponds  to 
the  experience  that  the  diminished  formation  of  lymphocytes  after 
operative  interference  is  overcompensated  during  convalescence. 

In  a  few  cases  a  slight  increase  of  the  eosinophiles  has  been 
observed.  This  too  could  be  regarded  as  a  post-infective  or 
post-toxic  process,  and  cannot  be  regarded  as  justifying  the 
conclusion,  at  present  at  all  events,  that  the  bone  marrow  in 
human  beings  takes  on  a  vicarious  function.  It  is  not  an 
infrequent  find  that  a  considerable  increase  in  the  eosinophiles 
is  present  in  splenic  tumours,  but  the  cause  of  this  is  probably 
to  be  sought  in  the  disease  itself  and  not  in  the  loss  of  splenic 
function. 

It  is,  however,  essential  that  further  careful  observations  in 
human  pathology  are  needed  to  clear  up  this  question. 

In  the  meantime,  direct  histological  examination  has  become 
applicable  for  the  study  of  the  participation  of  the  spleen  in  the 
formation  of  the  blood.  By  means  of  modern  section  staining  a 
perfectly  clear  insight  into  the  conditions  is  rendered  possible  by 
these  methods,  at  all  events  as  far  as  the  majority  of  the  points 
under  discussion  are  concerned. 

These  examinations  show  that  the  normal  human  spleen  does 
not  contain  any  nucleated  red  blood  corpuscles.  Only  a  few 
authors  claim  to  have  seen  a  few  such  cells.  It  can  therefore  be 
definitely  stated  that  the  human  spleen  during  adult  life  takes  no 
part  in  the  production  of  erythrocytes,  or  at  all  events  no  material 
part. 

The  same  applies  to  the  occurrence  of  myelocytes,  the  precur- 
sors of  the  polymorpho-nuclear  blood  cells.  These  cells  are  not 
met  with  in  stained  sections,  although*  a  few  authors  state  that 
single  examples  of  these  types  have  been  seen  on  rare  occasions. 

The  spleen  has  therefore  nothing  to  do  with  the  normal 
formation  of  the  polymorpho-nuclear  leucocytes ;  this  takes  place 
exclusively  in  bone  marrow. 


THE  WHITE   P,LOOI)  COIMM  ^SCLKS      115 

On  the  other  hand,  one  origin  of  tlio  lymphocytes  in  found  in 
the  M)ili)igliiiui  bodios,  iind  there  (;aii  bo  no  doubt  that  a  certain 
proportion  of  the  lyini)hocytes  of  the  blood  proceed  from  the 
spleen.  The  spleen  would,  aceordiug  to  Ibis  jxiiiit  of  vinvv,  belong 
to  the  lymphatic  system. 

The  cells  of  the  splenic  pulp,  however,  must  still  be  taken 
into  consideration.  Up  to  the  present  the  significance  and  char- 
acter of  these  cells  are  quite  unlcnown,  and  information  on  this 
point  can  only  be  obtained  by  means  of  the  most  dolicatci  methods 
of  cell  analysis. 

The  normal  functions  of  the  spleen  must  be  regarded  as 
including  a  process  whereby  a  portion  of  the  used-up  white  and 
red  blood  cells  are  completely  disintegrated  and  the  utilisable 
material  is  used  for  the  reconstruction  of  new  cells.  Spodogenous 
tumours  of  the  spleen  are  consequently  met  with  in  many  diseases 
(from  a'TTo'hoc  =  fragments). 

Comparative  anatomy  and  histology,  however,  teach  that  in 
some  of  the  lower  vertebrates  and  in  many  mammalians,  e.g.  mice 
and  rabbits,  the  spleen  fulfils  a  much  more  important  part  in 
the  formation  of  blood.  Nucleated  red  blood  corpuscles  may  be 
found  in  nests,  and  the  same  applied  with  regard  to  the 
myelocytes,  so  that  as  far  as  these  animal  species  are  concerned 
there  is  no  doubt  that  this  organ  possesses  a  blood-forming 
activity. 

With  regard  to  human  beings,  observations  of  this  kind  have 
only  been  made  under  embryonal  or  pathological  conditions. 
These  observations  have  been  made  quite  recently,  although  some 
finds  of  an  unconvincing  nature  have  been  reported  during  the 
past  two  decennia.  It  is  now  known  that  the  human  spleen  in 
the  early  stages  of  embryonal  life  at  first  exercises  an  erythro- 
poietic and  myeloid  activity  exclusively  (Naegeli,  Schridde).  In  a 
foetus  of  from  10 J  to  llf  inches  length  the  spleen  is  composed 
of  almost  pure  myeloid  tissue,  so  that  even  an  experienced  histo- 
logist  would  diagnose  bone  marrow  at  first  sight  from  a  smear. 
Later  on  this  function  diminishes  little  by  little,  until  the 
lymphatic   structures   are   developed  in    the  Malpighiau    bodies, 


116  ANAEMIA 

and  at  the  time  of  birth  the  spleen  has  lost  nearly  all  traces  of 
its  former  myeloid-erythropoietic  functions. 

Under  pathological  conditions,  however,  the  human  spleen 
may  again  harbour  erythroblasts  and  myelocytes,  as  if  it  had 
reverted  to  its  embryonal  habits.  Under  these  conditions  the 
cells  mentioned  are  not  merely  washed  into  the  organ.  Actual 
formations  and  even  quite  extensive  transformations  can  at  times 
be  discerned,  in  which  the  lymphatic  tissue  of  the  follicles  is 
reduced  or  even  stifled  and  substituted. 

Observations  of  this  nature  have  been  reported  in  such  great 
numbers  during  the  past  few  years  that  it  is  impossible  even  to 
name  the  individual  authors  responsible  for  them.  Suffice  it, 
therefore,  to  mention  that  this  form  of  transformation  in  the 
structure  and  function  of  the  spleen  actually  takes  place.  The 
conditions  under  which  this  occurs  include  the  infective  diseases, 
severe  ansemias  of  various  origins,  malignant  tumours,  provided 
that  they  have  led  to  anaemia  or  destruction  of  the  bone-marrow 
tissue  (carcinoma  of  the  medulla  of  bone),  and  especially  leukaemia 
and  the  allied  conditions. 

Experimental  research  did  not  have  any  great  difficulty  in 
discovering  some  absolutely  analogous  histological  appearances. 
A  complete  transformation  of  the  spleen  was  produced  in  experi- 
mental anaemia  caused  by  blood  poisons,  b}''  artificial  infections, 
and  by  exposure  to  X-rays  (K.  Ziegler).  It  is  proposed  to  discuss 
how  such  a  surprising  phenomenon  may  be  brought  about  later  on. 

Consequently  it  is  necessary  to  adhere  to  the  view,  which 
Ehrlich  formulated  with  considerable  precision  some  years  ago, 
that  the  normal  human  spleen  does  not  participate  in  the  forma- 
tion of  the  red  blood  corpuscles  and  of  myeloid  tissue  ;  but,  in 
opposition  to  the  older  views,  this  formation  takes  place  in  the 
spleen  frequently  and  at  times  extensively  under  pathological 
conditions,  like  a  reflection  of  embryonal  times. 

(b)    The  Lymphatic  Glands 

Since  it  is  impossible  experimentally  to  eliminate  all  the 
lymphatic  glands  from  taking  part  in  the  formation  of  blood,  it 


THE  WHITE  IJLOOD  CORPUSCLES     117 

is  necosKiU'y  io  (lo[)(!ii(l  eiitiroly  on  clinical  and  liiHloltjgical 
observiitions  i'or  the  [)urpoHO  of  obtaiiiiiif^  irifoi'inatiori  on  this 
subject. 

Since  Virchovv  dolnied  lynijjliocyteH,  the  identity  of  the 
lymphocytes  of  the  bl(Kjd  and  tlie  lyni])liocyte8  of  the 
lymphatic  glands  and  those  of  othcu'  forms  of  lymphatic 
tissue,  be  they  l;i,rg(!  or  small  types,  iiiis  not  been  questioned. 
This  identity  is  proved  by  the  complete  correspondence  of  the 
general  morphological  characters,  and  of  the  tinctorial  peculiarities 
both  of  the  protoplasm  and  of  the  nucleus. 

With  regard  to  the  granules  in  the  lymphocytes,  the  proof 
of  the  identity  of  the  blood  lymphocytes  and  those  of  the 
lymphatic  glands  can  be  further  clinched  by  the  demonstration 
of  Schridde-Altmann's  fuchsinophile  perinuclear  granulation, 
which  is  possible  in  every  lymphocyte  in  lymphatic  glands. 
In  the  same  way,  some  of  the  lymph  cells  show  azure  granules. 
The  identity  is  therefore  complete  in  this  respect  also,  and 
since  both  these  forms  of  granulation  do  not  occur  in  any  other 
cells  save  the  lymphocytes,  the  correspondence  may  be  regarded 
as  absolutely  proved.  Now,  since  similar  cells  (myeloblasts) 
occur  in  the  parenchyma  of  the  bone  marrow,  which,  however, 
do  not  show  these  specific  characters  (Schridde,  Naegeli),  it 
follows  that  the  bone  marrow  does  not  produce  any  lymphocytes 
normally.  The  differential  distinction  between  the  two  cells  is 
shown  in  this  way.  Only  a  few  isolated  lymphocytes  are  met 
with  in  the  sheaths  of  the  vessels  of  the  medulla. 

It  is  characteristic  of  the  advance  in  hsematology  due  to 
Ehrlich's  teaching  that  a  direct  proof  of  identity  and  new 
formation  of  cells  is  now  forthcoming,  while  formerly,  owing  to 
the  absence  of  good  section  staining,  the  observer  was  forced 
to  rely  on  indirect  methods  which  were  far  less  certain. 

Ehrlich  based  his  doctrine  of  the  origin  of  the  lymphocytes 
from  the  lymphatic  glands  chiefly  on  biological  grounds.  He 
pointed  out  that  when  extensive  areas  of  lymphatic  tissue  were 
eliminated  by  new  growths  and  similar  changes,  the  number 
of  lymphocytes   was  sensibly  diminished.     This   fact    has    since 


118  ANEMIA 

been  confirmed  by  a  number  of  authors.  For  example, 
Eeinbacli  described  several  cases  of  malignant  tumours,  especi- 
ally sarcomata,  in  which  the  percentage  of  lymphocytes, 
which  is  usually  about  25,  was  very  materially  diminished : 
in  one  case  of  lympho-sarcoma  of  the  neck  these  cells  only 
represented  0'6  per  cent,  of  the  total  number.  The  author 
observed  a  case  (published  in  the  J.  D.  Chotimsky,  Zurich,  1906) 
of  general  enlargement  of  the  lymphatic  glands,  in  which, 
during  the  course  of  two  years,  the  absolute  value  of  the 
lymphocytes  varied  in  a  large  number  of  counts  between  300 
and  500,  as  compared  with  the  normal  2000.  In  spite  of  the 
extraordinary  generalisation  of  the  process,  which  suggested  an 
aleuksemic  early  stage  of  a  lymphatic  leuksemia,  this  diagnosis 
could  be  definitely  excluded  on  account  of  the  biological- 
functional  phenomena,  and  a  process  of  destruction  of  the  active 
lymphocyte-producing  tissue  had  to  be  assumed.  The  post- 
mortem examination  and  subsequent  histological  investigation 
showed  that  the  case  was  one  of  a  tuberculosis,  having  the 
course  of  a  pseudo-leuksemia  and  leading  to  complete  induration 
and  scarring  of  the  glandular  tissue. 

These  appearances  can  be  explained  quite  readily  and  naturally 
on  the  assumption  of  the  elimination  of  the  lymphatic  glands. 
It  is  difficult  to  say  how  the  supporters  of  the  view  that  the 
lymphocytes  are  the  precursors  of  all  white  blood  corpuscles 
can  explain  these  facts.  In  accordance  with  this  view,  it  would 
have  to  be  assumed  that  the  small  number  of  lymphocytes  in 
such  cases  would  be  accounted  for  by  supposing  that  an 
unusually  rapid  transition  into  the  elder  forms,  the  poly  nuclear 
elements,  had  occurred,  or,  to  adopt  Uskoff's  vernacular,  that  a 
premature  getting  old  of  the  lymphocytes  had  taken  place. 

Further  proof  that  the  blood  lymphocytes  are  derived  from  the 
lymphatic  glands  can  be  obtained  from  those  cases  in  which 
an  increase  of  lymphocytes  in  the  blood  is  found.  These 
lymphocytoses  are  of  rare  occurrence  as  compared  with  other 
forms  of  leucocytosis.  In  the  first  place,  it  can  be  seen  that 
certain    conditions,  in  which    a    hyperplasia    of    the    lymphatic 


THE  WJIITK  iJLooi)  c  ()iiiM;sc:Li:s    llj 

gland  apparatuH  occurs,  an:  aissociaLed  vviLli  ;iii  iiicicasc  oi 
lymphocytes  in  the  l^lood.  I^>liilicli  iiiid  l\;M(;\\Hki  f;xaiiiincd  a 
long  series  of  typicaJ  cases  of  ]yiiipli<»iii;i,  niali.^iniin  (l/licy  did  not 
publish  tlieir  icsulls).  'I'lu'.y  noted  ;i,  r("j,id;ii-  lympliocytosiK 
which  was  veiy  considei'al)l(!  in  souk;  of  Hk;  c.jises  ;M,d  li;id  almost 
a  leulvtx'niic  character. 

On  the  bases  of  tlicsn  ivsnlts,  I'llulicli  ;i,iid  Wasscrinaim 
(^Dermafolor/isrhe  Zcr/Kclir///,  J804,  vol.  i.)  foinKid  tjic  diagnosis  of 
malignant  lympliomu  during  life  in  a  fa.'^n  of  a  rarn  foim  of  .skin 
affection.  The  lilood  showed  an  absohite  increase,  wliicli  was  limited 
to  the  lymphocytes.  No  swelling  of  the  lymjiliatic  glands  was 
ascertained  by  })alpation.  The  post-mortem  examination  revcilcd  that 
the  retroperitoneal  lymphatic  glands  were  swollen  to  the  size  of  a  fist. 

In  cases  of  this  kind  there  is  a  marked  increase  of  pro- 
duction of  lymphocytes  in  the  whole  lymphatic  apparatus,  as 
can  be  proved  by  histological  preparations.  Some  parts  of  the 
apparatus  no  doubt  are  but  slightly  affected,  but  the  proliferation 
is  well  marked  in  others.  This  means  that  there  is  a  system 
affection  of  the  lymphatic  apparatus,  which  in  view  of  its  nature 
is  termed  lymphocytomatosis.  This  affection  may  last  for 
several  years  and  may  pass  on  to  a  true  lymphatic  lenkiemia, 
from  which  it  differs  oidy  in  point  of  extension. 

It  is  therefore  possible  to  gain  information  with  regard  to 
the  natirre  of  certain  affections  of  the  lymphatic  glands  on 
biofunctional  considerations,  and  at  the  same  time  to  determine 
essential  differences  between  the  various  forms,  even  when 
the  clinical  appearances  do  not  serve  to  clear  np  the  matter. 
It  must,  of  course,  be  realised  that  these  considerations  can 
only  be  regarded  as  correct  and  utilisable  if  the  anatomic 
histological  premise  corresponds  to  fact,  namely,  that  the  lym- 
phatic glands  are  the  sites  of  origin  of  the  lymphocytes. 

Proof  has  recently  beeir  adduced  that  in  the  earliest 
embryonal  stages,  before  the  lymphatic  apparatus  has  been 
developed,  no  lymphocytes  are  found  in  the  blood,  and  that  the 
blood  then  contains  cells  of  the  mveloid  series  exclusivelv. 


120  ANAEMIA    ■ 

It  is,  as  would  be  expected,  extremely  difficult  to  say  how 
large  a  proportion  of  the  lymphocytes  is  derived  from  the 
lymphatic  glands.  The  lymphatic  follicles  of  the  intestinal 
tract  and,  as  has  already  been  mentioned,  the.  spleen  un- 
doubtedly supply  the  blood  with  true  lymphocytes.  But  the 
clinical  experiences  made  in  cases  of  destruction  of  lymphatic 
glands,  to  which  allusion  has  been  made,  goes  to  show  that  the 
preponderance  of  these  cells  originate  in  the  glands.  If  this 
were  not  so  it  would  be  extremely  difficult  to  explain  the  very 
low  values  which  have  been  observed  and  which  persist  for 
years. 

A  marked  diminution  of  the  lymphocytic  value  is  met 
with  frequently  and  with  considerable  regularity  in  acute 
diseases,  and  especially  in  the  early  stages  of  the  infective 
processes.  This  diminution  is  resolved  in  the  later  stages  by  an 
increase  in  the  absolute  numbers  which  may  attain  a  quite 
considerable  degree  during  convalescence.  Under  these  con- 
ditions, even  if  it  cannot  be  said  that  histological  changes  are 
not  present,  the  changes  must  depend  to  a  large  extent  on 
functional  factors,  such  as  the  toxic  inhibition  of  the  cyto- 
genesis  and  a  consequent  hyperactivity,  according  to  general 
biological  laws.  It  is  just  the  late  increase  which  cannot 
possibly  be  explained  otherwise  than  as  a  biofunctional  process. 

Consequently  the  phenomena  of  hypo-  and  hyper-lympho- 
cytosis  must  always  be  judged  with  caution,  and  it  is  essential  in 
all  cases  to  think  of  the  possibility  of  functional  changes  rather 
than  of  gross  anatomical  lesions,  although  even  when  the  former 
are  active  the  latter  need  not  be  excluded.  An  example  of 
this  may  be  quoted  in  the  later  stages  of  pertussis  and  of  enteric 
fever,  when  enlargement  of  the  lymphatic  glands  is  met  with. 
This  enlargement  should  be  regarded  as  the  anatomical  substratum 
of  the  existing  increase  of  lymphocytes. 

Chemical  substances  induce  a  preliminary  diminution  in  the 
number  of  lymphocytes  in  the  blood  as  the  result  of  a  functional 
process  (toxic  inhibition  of  the  cytogenesis),  while,  as  is  well 
known,  the  myeloid  system  usually  reacts  to  a  stimulation  of  the 


THE  WHITE  ]}L()()1)  COllPUSCLES     121 

funciioiiH  of  tli(!  organs  l»y  a  inarkfid  IciicDcytDsis.  An  inf,roa80 
of  tlie  lympliocylcB  only  lakn.s  placo  lat(!r  as  an  af'tor-oircct,  in 
accordance  with  biologic-al  laws.  This  r'(^ac,liv(;  increase  conlinuoB 
beyond  Uh;  noi'inal  niveau  as  ilio  function  recovers  itself. 

Hitiioi'to  only  one  substance  lias  been  mentioned  in  literature 
which  is  stated  to  l.)e  capal)l(;  by  itself  of  ])roducing  a  lym- 
phocytosis. Waldstein  reports  that  he  lias  succer^dcd  in 
inducifig  a  lymplia3mia  by  injecting  pilocarpine.  On  increasing 
the  number  of  injections  he  ol)tained  a  progressive  chaiucter  of 
the  changes. 

Observations  of  this  kind  do  not  jjrove  much,  since  an 
aleukicmic  lymphocytosis  may  at  any  time  pass  over  to  its 
leukfcmic  stage  and  then  assume  a  progressive  character.  It 
appears  to  be  exceedingly  doubtful  whether  pilocarpine  can 
induce  a  primary  and  not  secondary  functional  lymphocytosis  on 
an  unprepared  soil,  and  would  have  to  be  proved  by  repeated 
careful  investigation  before  it  could  be  accepted. 

The  production  of  a  lymphocytosis  therefore  depends  on 
absolutely  different  causes  to  those  which  act  in  producing  the 
ordinary  leucocytoais  in  which  an  increase  of  the  noutrophile 
elements  is  found.  As  Ehrlich  pointed  out  long  ago,  the  chief 
difference  is  found  in  the  fact  that  chemotactic  functions  play  a 
principal  part  in  the  production  of  leucocytosis,  and  that  this 
exercises  a  distant  action  on  the  bone  marrow.  In  lymphocytosis 
this  chemotaxis  is  not  present,  or  is  only  present  to  a  very 
slight  extent.  A  primary  increase  of  lymphocytes  is  therefore 
unknown. 

On  the  other  hand,  it  can  be  said  at  present  that  secondary 
lymphocytosis,  which  is  seen  in  the  later  stages,  cannot  be 
regarded  solely  as  the  result  of  an  increase  in  the  lymph 
circulation,  which  would  mechanically  cause  a  larger  number  of 
the  elements  to  be  washed  out  of  the  lymphatic  glands. 

Clinical  observation  has  taught  that  a  functionally  augmented 
activity  sets  in  during  recovery  after  the  stage  of  diminished 
function,  which  is  usually  a  sign  of  toxic  inhibition,  and  that  the 
hyperlymphocytosis  is  then  the  expression  of  a  true  increase  of 


122  ANEMIA 

function.  It  is  therefore  necessary  to  add  the  functional 
explanation  to  the  mechanical  explanation  formulated  above. 
In  the  same  way,  in  severe  pathological  affections  involving  an 
actual  proliferation  of  the  lymphatic  tissue,  as  in  lymphocyto- 
matosis  and  lymphatic  leukaemia,  a  marked  increase  of  activity 
of  the  tissue  takes  place  and  not  a  mere  mechanical  washing 
out. 

The  lymphocytes  do  not  play  any  part,  as  a  rule,  in 
inflammatory  processes,  and  are  not  met  with  in  the  in- 
flammatory foci.  This  corresponds  to  the  absence  of  a 
chemotactic  attraction. 

Neumann  described  many  years  ago  a  highly  interesting 
experiment  bearing  on  this  question.  He  produced  an 
abscess  in  a  patient  who  was  suffering  from  lymphatic 
leukaemia,  and  whose  blood  contained  a  very  small  number  of 
polynuclear  cells.  The  pus  was  found  on  examination  to  consist 
exclusively  of  polynuclear  leucocytes ;  not  a  single  lymphocyte 
was  found  in  the  discharge,  although  the  blood  was  full  of 
these  cells. 

The  same  results  have  been  obtained  each  time  this 
experiment  has  been  repeated. 

If,  in  spite  of  this,  lymphocytes  leave  their  vessels  actively, 
and  this  has  been  observed  several  times  (Schridde,  Helly,  and 
others),  quite  a  different  cause  must  prevail  to  that  wdiich  prevails 
in  ordinary  leucocytosis. 

Histological  examination  of  nearly  all  fresh  inflammatory 
processes  in  which  the  polynuclear  elements  alone  are  found  in 
the  inflammatory  tissue  also  yields  results  conforming  to  this 
view.  Under  exceptional  conditions  lymphocytes  may  pass  out 
of  the  vessels  in  the  earliest  stages  of  fresh  inflammations. 
There  must  in  this  case  be  special,  undoubtedly  different  attrac- 
tions to  those  which  act  on  the  leucocytes.  In  the  case  of 
migration  of  lymphocytes  a  local  action  of  the  vascular  wall 
and  the  tissue  in  its  immediate  environment  must  take  place, 
and  not  a  distant  action,  which  reaches  as  far  as  the  blood- 
forming  organs.     It  is  well  known  that  in   the  later   stages   of 


THE  WHITE   HLOOI)  (OllIMISCLKS     12:5 

in(liUiiTn)i,t/i()ii  Kiuall  ('-(ill  in(ill,i'!il,ioii  !i,|)])e;u'H,  wliicli  cojisIkLh 
appiii'ciiLly  (jF  lyiiiphocytu.s.  J5uL  Ll)i,s  does  iioIj  provo  ilial  thfise 
lympliocytes  liavo  migratxid  from  tli(Mi'  vcHseln  io  the  nite  of 
iiillaiuiiialion.  IL  i.s  uiiiiedessary  in  this  |)l;i,('(;  to  enter  into  a 
discussion  of  the  controversy  which  has  h(;eii  eiiga^^iiig  tlie 
attention  of  a  number  of  lia'matologists  with  regard  to  this 
question.  It  will  be  sullicient  for  the  present  to  mention  that 
all  tlic  investigators  have  cousidcied,  in  the  (iist  place,  the 
possibility  of  a  new  formation  of  the  colls  in  aitu.  Evidence  of 
this  occurrence  has  been  forthcoming  in  the  examination  of  the 
blood  in  tubercular  pleurisy.  In  spite  of  the  fact  that  a 
lymphocytosis  exists  from  the  earliest  stages  in  the  exudation, 
no  increase  of  the  lymphocytes  in  the  blood  is  seen.  In  every 
chemotactic  increase  the  rule  is  that  increase  in  numbers  of  a 
certain  species  of  cell  finds  a  corresponding  increase  of  the  same 
cells  in  the  blood. 

It  therefore  follows  from  clinical  and  morphological  ex- 
aminations, and  also  from  the  results  of  investigations  of  inflam- 
matory processes,  that  the  lymphocytes  do  not  stand  in  any 
correlation  to  the  polynuclear  leucocytes.  The  same  result  will 
be  arrived  at  in  a  different  way  in  the  following  chapter. 

Erythropoesis  and  formation  of  myelocytes  have  within 
recent  times  been  observed  under  pathological  conditions  in  the 
lymphatic  glands,  just  as  they  have  been  seen  in  the  spleen. 
The  analogy  with  the  conditions  obtaining  in  connection  with  the 
spleen  is  a  perfect  one.  During  the  embryonal  period  the  myeloid 
tissue  at  first  claims  a  place  in  the  lymphatic  glands  as  well, 
and  only  disappear  gradually  as  the  bone  marrow  develops.  In 
post-embryonal  periods  the  central  portions  of  the  glands 
undergo  a  myeloid  transformation,  in  severe  antemias,  in  infec- 
tions, and  intoxication.  This  takes  place  more  especially  when 
the  organism  calls  forth  new  fields  for  the  production  of  the 
vitally  essential  red  blood  corpuscles  and  myeloid  leucocytes,  in 
compensation  for  defective  function  of  bone  marrow. 


124  ANEMIA 

(c)  The  Bone  Marrow 

It  was  fermerly  thought  that  the  spleen  and  lymphatic 
glands  were  the  only  organs  of  production  of  the  blood 
corpuscles,  but  general  attention  was  attracted  to  the  bone 
marrow  by  the  investigations  of  Neumann  and  a  little  later  of 
Bizzozero,  in  which  it  was  shown  that  the  precursors  of  the  red 
blood  corpuscles  are  formed  in  these  organs.  This  discovery  was 
rapidly  recognised,  and  was  soon  turned  to  practical  use  in 
pathology  by  Cohnheim  and  others.  In  this  connection,  especially 
valuable  information  was  adduced  in  the  fact  that  after  severe 
htemorrhage  the  medulla  of  the  long  bones  was  reconverted  into 
red  marrow,  which  shows  that  the  regenerative  function  of  the 
bone  marrow  may  meet  an  increased  demand. 

No  other  site  of  production  of  red  blood  corpuscles  in  man 
under  normal  conditions  is  known.  In  other  mammalians,  as 
has  already  been  mentioned  (see  p.  115),  the  spleen  may  partici- 
pate to  a  certain  extent  in  the  production  of  erythrocytes.  The 
type  according  to  which  the  normal  production  of  blood  is 
carried  out  in  adults,  and  the  variations  from  this  type  which 
are  met  with  in  pernicious  anaemia,  have  been  discussed  in 
detail  in  the  chapter  on  the  red  blood  corpuscles,  and  Ehrlich's 
views  were  accorded  their  proper  significance,  according  to  which 
the  production  of  blood  in  Biermer's  ansemia  follows  quite  a 
different  type,  and  one  which  is  analogous  to  the  embryonal 
type. 

It  is  therefore  only  necessary  in  this  chapter  to  consider  the 
white  blood  corpuscles  and  their  relation  to  the  bone  marrow. 
In  man,  as  well  as  in  a  number  of  other  animals  {e.g.  monkey, 
guinea-pig,  rabbit,  pigeon,  etc.),  the  bone  marrow  shows  a 
peculiarity  in  that  the  cells  which  it  produces  contain  specific 
and  easily  demonstrable  granulations.  This  is  sharply  contrasted 
to  the  lymphatic  system,  the  granules  of  which  are  quite 
difterent,  and  which  differ  among  themselves.  Some  of  the  latter, 
such  as  the  azure  granules  and  Schridde's  fuchsinophile  granules, 
were  not  recognised  for  a  very  long  time. 


THE  WHITE  BLOOD  CORPUSCLES      125 

The  azuro  <i,'ninu](iM  arc  only  I'oiiiid  in  Honirs  of  Uio  lyniijlio- 
cytes,  and  possesH  qiiit(i  a,  (li('r(!r(Mif,  bioloj^ical  Kij^nificancc  to  the 
acidophile,  eosinophile,  and  mast  ccdl  nranulcs.  Ah  Papponhoini 
has  pointed  out,  the  azure  reaction  lA'  tlic;  granulations  in  not 
specific  and  niiiy  occur  even  in  throiubocytes  of  fro^fs  and  in 
carcinoma  cells. 

A  very  important  classification  into  two  groups  can  be 
recognised  in  the  granulated  cells  of  the  bone  marrow. 

The  first  group  of  the  "special  granules"  claims  especial 
consideration,  because  they  arc  the  characteristic  sign  of  certain 
animal  species.  They  show  varying  tinctorial  and  morphological 
behaviour  according  to  the  species  of  animal.  For  example,  they 
have  a  neutrophile  granulation  in  man  and  in  the  monkey ; 
they  have  what  KurlolT  described  as  a  pseudo-eosinophile 
granulation  in  the  guinea-pig  and  rabbit ;  in  birds  two  specific 
forms  of  granulation  exist  side  by  side.  Both  of  these  are 
oxyphile.  and  while  the  one  occurs  in  crystal  form,  the  other 
is  deposited  as  granules  in  the  protoplasm.  The  forms  of  special 
granules  which  have  been  studied  hitherto  have  one  characteristic 
in  common,  namely,  that  they  stain  with  acid  or  neutral  dyes, 
but  show  a  much  smaller  affinity  to  the  dye  bases.  The  fact 
that  the  number  of  these  granules  far  exceeds  that  of  any  of  the 
other  elements  of  the  bone  marrow  shows  how  important  they  are. 

The  second  group  of  the  bone  marrow  cells  contains  granules 
which  are  found  in  the  whole  series  of  vertebrate  animals,  from 
the  frog  up  to  man,  and  which  are  therefore  not  characteristic 
of  any  one  species.  These  are :  (1)  the  eosinophile  cells,  and 
(2)  the  basophile  mast  cells. 

The  mononuclear  cells  represent  the  non-granulated  cells  of 
bone  marrow.  Under  normal  conditions  they  are  less  abundant 
and  probably  less  important  than  the  granulated  cells,  and 
especially  than  the  predominating  first  group  of  granulated  cells. 
Under  pathological  condition,  however,  this  is  not  so. 

Of  the  non-granulated  cells,  the  giant  cells  deserve  special 
mention,  because  they  are  an  almost  constant  component  of  bone 
marrow  in  mammals. 


126  ANEMIA 

It  has  been  shown  by  the  study  of  embryology  and  histology 
that  the  giant  cells  of  bone  marrow  parenchyma  are  intimately 
connected  with  the  myeloid  tissue,  and  are  usually  met  with 
whenever  pathological  conditions  lead  to  fresh  myeloid  formation 
of  cells. 

When  a  stained  dry  preparation  of  bone  marrow  of  the 
guinea-pig,  rabbit,  or  man  is  examined  it  will  be  seen  that 
characteristic  finely  granulated  cells  are  present  in  all  stages  of 
development,  from  the  mononuclear  cells,  through  the  transition 
forms  to  the  polymorpho-nuclear  cells,  just  as  is  the  case  in 
circulating  blood.  A  glance  at  such  specimens  proves  that  the 
bone  marrow  is  the  incubator  in  which  typical  polynuclear 
cells  are  constantly  being  formed  from  the  granulated  mono- 
nuclear cells. 

The  same  method  of  maturing  can  also  be  observed  with 
regard  to  the  polynuclear  eosinophile  leucocytes. 

Ehrlich  was  able  by  means  of  special  differential  staining  to 
supply  evidence  of  the  fact  that  during  the  transformation  of 
the  mononuclear  cells  to  the  polynuclear  the  kind  of  granulation 
also  changes.  In  the  young  granules  the  basophile  type  is 
predominant,  but  as  the  cells  mature  this  type  becomes  less 
marked.  Thus  the  pseudo-eosinophile  granules  of  the  mono- 
nuclear cells  of  the  guinea-pig  stain  bluish  red,  after  prolonged 
fixation  in  superheated  steam  and  staining  with  eosin-methylene- 
blue ;  in  the  transition  forms  this  blue  tone  gradually  becomes 
weaker,  until  at  last  the  granules  of  the  polynuclear  leucocytes 
stain  pure  red  without  any  blue  admixture.  Similar  observations 
may  be  made  with  the  eosinophile  cells  of  the  human  subject 
and  of  animals,  and  with  the  neutrophile  cells  of  the  human 
subject.  It  has  therefore  become  possible  to  decide  whether  a 
single  granule  belongs  to  a  young  or  to  an  old  cell. 

It  is  at  present  unknown  how  rapidly  the  process  of  maturing 
of  the  mononuclear  cells  into  polynuclears  is  completed,  or 
whether  the  granules  mature  at  the  same  rate  as  the  cell  as 
a  whole.  Nevertheless,  the  author  is  of  opinion  that  some 
observations   go  to  show  that  both   these  processes    take   place 


THE  WHITE  JJLOOl)  COJIPUSCLES     127 

eimiiltancouBly,  and  that  in  special  casoH  the  morpholoj^ical 
ripenino-  of  tlie  ccIIh  ])rocee(lH  at  a  iiioi'o  ra])i(l  pace  than  th;i.t  of 
the  granules.  It  is  especially  easy  to  collect  evidence  of  this 
nature  with  cosinoi)hilo  cells.  7\b  early  as  1878,  in  his  first 
publication,  Ehrlich  stated  that,  a])art  from  the  typical  cosinophile 
granules,  other  single  granules  were  frerjuently  met  with  which 
showed  a  different  tinctorial  behaviour;  for  example,  when 
stained  with  eosin-aurantia-nigrosin,  they  appeared  nearly  black, 
or  when  the  eosin-methylene-blue  mixture  was  used  they  took 
on  a  bluish  red  or  even  a  pure  blue  colour.  Ehrlich  recognised 
these  forms  even  at  that  time  as  young  elements.  The  same 
well-marked  differences  are  met  with  in  leuktemia,  in  the 
circulating  blood  affecting  both  the  neutrophile  and  the  cosino- 
phile groups.  Ehrlich  has  repeatedly  come  across  polynuclear 
eosinophile  cells  in  leuktemic  blood,  in  which  the  granules  had 
to  be  regarded  almost  exclusively  as  young  forms.^ 

Ehrlich  regarded  this  phenomenon  in  leuka3mic  blood  as  an 
expression  of  a  typical  hastening  .of  the  morphological  process 
of  maturing,  as  compared  with  the  slower  development  of  the 
granules. 

Only  the  mature  forms  of  the  specific  granulated  leucocytes 
which  occur  in  bone  marrow  are  found  in  normal  blood,  while 
the  mononuclear  and  transition  forms  of  the  neutrophile  group  do 
not  pass  over  into  the  circulation  under  normal  conditions  at  all. 

Since  these  cells  are  only  found  in  bone  marrow,  and  are 
never  present  under  normal  conditions  either  in  the  spleen  or  in 
the  lymphatic  glands,  Ehrlich  regarded  the  mononuclear  neutro- 
phile granulated  cells  as  the  most  characteristic  of  bone  marrow, 
and  therefore  named  them  kolt  i^oy/iv,  "  myelocytes."  Whenever 
myelocytes,  no  matter  of  what  size,  appear  in  the  blood  of  adults 

*  This  double  staining  of  the  eosinophile  granules  has  been  interpreted  by 
many  authors,  e.g.  Arnold,  on  the  assumption  that  eosinophile  and  mast  cell 
granules  can  occur  simultaneouslj'^  in  one  and  the  same  cell.  That  this  is  not 
correct  is  shown  by  the  fact  that  alleged  "basophile"'  granulation  of  the 
eosinophile  cells  does  not  show  the  characteristic  metachromasia  of  the  mast 
cells  when  stained  by  the  usual  metachromic  staining  methods,  and  that  when 
Giemsa  is  used  the  precursors  take  on  a  blue  and  not  a  mauve  colour,  as  is  the 
case  in  mast  cells. 


128  ANiEMIA 

in  considerable  numbers  a  very  severe  disturbance  of  the 
leucocyte  production  may  with  certainty  be  assumed.  It  must, 
however,  be  pointed  out  that,  even  when  moderate  numbers  are 
present,  the  diagnosis  of  leukaemia  is  not  necessarily  justified, 
since  it  does  occur  that  even  in  curable  affections,  and  especially 
in  severe  forms  of  anaemia,  10  per  cent,  and  more  myelocytes 
are  present.     This  is,  however,  extremely  rare. 

In  this  connection  an  observation  made  by  Morawitz  is 
particularly  instructive.  In  a  case  of  necrotic  tonsillitis  a  very 
severe  anaemia  had  developed,  and  the  blood  of  this  patient 
showed  an  enormous  quantity  of  normo-  and  megalo-blasts. 
The  neutrophile  myelocytes  in  the  blood  were  found  to  correspond 
to  20  per  cent,  of  22,100  leucocytes  per  c.mm.,  and  the  eosinophile 
myelocytes  at  times  to  1  per  cent.  Improvement  took  place  after 
transfusion  of  blood,  and  the  patient  eventually  recovered. 

It  is,  however,  generally  true  that  high  myelocyte  values, 
especially  if  associated  with  a  high  total  number  of  white  blood 
corpuscles,  must  be  regarded,  as  the  most  important  symptom 
of  a  myeloid  leukaemia. 

Precisely  similar  conditions  hold  good  for  the  eosinophile  cells. 
The  mononuclear  cells  in  this  case  also  (known  as  eosinophile 
myelocytes)  occur  in  large  quantities  almost  exclusively  in 
leukaemic  blood.  This  find,  which  was  first  analysed  by  H.  F. 
Miiller,  represents  a  less  useful  indication,  since  the  chief  mass 
of  the  foreign  elements  of  the  blood  of  myeloid  leukaemia  is 
made  up  to  a  large  extent  of  Ehrlich's  myelocytes. 

These  observations  admit  of  very  important  conclusions  with 
regard  to  the  question  of  leucocytosis.  When  it  is  considered 
that  the  polynuclear  neutrophile  cells  are  only  developed  from 
and  stored  up  in  bone  marrow,  and  that  in  ordinary  leucocytosis 
only  the  polymorphs  are  increased  in  the  blood,  it  becomes  clear 
that  leucocytosis  is  a  pure  function  of  bone  marrow.  Ehrlich 
has  always  insisted  rigorously  on  this.  It  is  on  this  basis  alone 
that  a  leucocytosis,  which  frequently  sets  in  with  extraordinary 
suddenness  (this  is  often  observed  in  diseases  as  well  as  in 
experimental  conditions)  can  be  satisfactorily  explained.     Under 


THE   WIiriK   n\AH)D  COJilMJSCLKS     129 

these  circumstanooH,  tli(3  Hpacc  of  time  (iui'in<r  which  the  develop- 
ment of  the  leucocytosis  takes  place,  whicli  ii)ay  he  limited  to 
a  few  minutes,  is  far  too  short  for  a  new  formation  of  leucocytes 
to  he  possihle.  It  tliuK  ;i,pj)ears  that  tlieit;  must  Ijc  a  place  where 
these  cells  are  stored  up  ready  for  use,  and  prepared  to  wander 
forth  in  response  to  every  suitahle  stimulus.  This  place  is  the 
bone  marrow,  and  no  other.  In  tliis  situation  tli(i  mononuclear 
elements  mature  gradually,  to  become  polynuclear  contractile 
cells,  in  which  condition  they  obey  every  chemotactic  stimulus, 
by  migrating  and  thus  produce  an  acute  leucocytosis. 

The  bone  marrow  thus  fulfils,  besides  its  other  functions,  the 
highly  important  task  of  a  protective  organ.  It  can  overcome, 
with  rapidity  and  energy,  certain  noxious  agents  which  threaten 
the  organism.  This  organ  is  at  all  times  prepared  to  avert  danger,, 
by  responding  promptly  to  each  and  every  call,  and  to  send  forth 
its  agents  to  take  up  the  fight  at  the  invaded  place  ;  it  may  indeed 
be  likened  to  a  well-organised  fire  brigade. 

It  should  be  mentioned  that  the  large  mononuclear  leuco- 
cytes and  the  transition  forms  of  normal  blood  are  involved  to 
a  certain  extent  in  the  increase  of  cells  in  ordinary  leucocytosis  ; 
the  same  applies  in  myeloid  leukaemia.  The  appearance  of  the 
former  kind  of  cell,  however,  in  leucocytosis  is  peculiar  and  is 
not  at  present  fully  understood.  The  reader  is  referred  to  K. 
Ziegler  and  Schlecht's  recent  work  on  the  subject. 

From  the  biological  point  of  view  there  can  be  no  doubt  that 
the  group  of  cells  of  the  transition  type,  among  which  Ehrlich's 
large  mononuclear  cells  must  be  included,  actually  belongs  to  the 
myeloid  system  and  is  developed  in  it. 

There  are  no  reasons  either  of  a  histological  or  of  any  other 
nature  which  would  justify  the  assumption  that  these  cells  are 
formed  in  the  spleen ;  and  there  is  also  no  proof  that  they  are 
formed  in  the  lymphatic  glands.  An  adventitial  normal  origin 
of  the  large  mononuclear  cells,  such  as  Helly  has  attempted  to 
substantiate,  has  certainly  not  been  proved  to  exist.  According 
to  this  theory,  these  cells  are  regarded  as  being  of  the  same 
species  as  the  lymphocytes,  and  are  termed  for  this  reasou 
9 


130 


ANiEMIA 


leucocytoid  lymphocytes.  In  the  opinion  of  the  author  this 
theory  has  been  definitely  disproved  by  the  more  minute 
analytical  methods,  especially  by  the  demonstration  of  neutro- 
philic granules. 

A  further  argument  in  favour  of  the  myeloid  origin  may  be 
sought  in  the  fact  that  large  mononuclear  cells  have  been  found 
in  increased  numbers  in  bone  marrow  as  well  as  in  the  blood. 
This  has  been  demonstrated  in  the  experiments  of  Nattan-Larier. 

It  is  therefore  possible,  on  the  basis  of  the  microscopical 
appearances,  to  conclude  that  the  bone  marrow  is  by  far  the 
most  important  blood-forming  organ,  and  that  the  red  discs  and 
also  the  chief  group  of  the  white  discs,  i.e.  the  polynuclear 
neutrophile  cells,  are  exclusively  formed  in  this  situation. 

Insurmountable  difficulties  are  placed  in  the  way  of  experi- 
mental physiological  examination  of  the  functions  of  the  bone 
marrow.  It  is  absolutely  impossible  to  eliminate  the  whole  bone 
marrow,  or  even  a  considerable  part  of  it,  by  means  of  operation. 
No  value  can  be  attached  to  the  attempts  to  determine  the 
function  of  the  bone  marrow  by  comparative  counts  of  the 
arterial  and  venous  blood  in  a  chosen  bone  marrow  area.  J. 
P.  Eoietzky,  working  under  the  direction  of  Uskoff,  has  carried 
out  counts  of  this  kind  in  the  dog,  using  the  blood  from  the 
nutrient  artery  of  the  tibia  and  from  the  corresponding  vein. 
He  found  that  the  number  of  white  blood  corpuscles  in  the  vein 
was  slightly  increased,  but  that  the  absolute  number  of  "  young 
blood  corpuscles "  (Uskoff),  i.e.  lymphocytes,  was  considerably 
diminished,  and  at  the  same  time  that  the  number  of  "  mature  " 
cells,  which  correspond  to  a  large  extent  to  what  are  usually 
termed  the  polynuclear  cells,  was  markedly  increased.  The 
following  table  shows  his  results  : — 


Total  Quantity. 

Young  Cells. 

Mature  Cells. 

Old  Cells. 

Arterial  blood 
Venous  blood 

15,000 
16,400 

1950(13-0%) 
656(4-0%) 

840(5-6%) 

2788(17-0%) 

12,210(81-0%) 

12,956(79-0%) 

THE  WHITE   P.EOOI)  COHIHJSCEES     131 

The  indispensable  liypothesiB  foi'  Uie  vulue  of  such  comparative 
counts  would  be  tlie  assumption  of  a  continuous  function  of 
the  bone  marrow,  and  UskofC  ay)j)cars  to  make  this  assumption. 
If  bone  marrow  can  absorb  the  lym])bocyt(',s  continuously  to 
such  a  degree,  it  would  be  difificult  to  understand  liow  the 
normal  condition  can  be  maintained  in  view  of  the  extent  of 
the  bone  marrow  and  the  rapidity  of  the  circulation.  There  is, 
however,  every  reason  to  suppose,  on  the  coiitra,ry,  tbut  t  lie  bone 
marrow  acts  intermittently,  since,  as  has  been  set  forth  in  detail 
in  the  preceding  pages,  elements  are  constantly  maturing  in  the 
bone  marrow  and  that  these  elements  only  migrate  at  certain 
epochs  in  response  to  chemical  stimuli.  From  this  argument  it 
would  follow  that  but  little  can  be  expected  from  the  results  of 
experimental  methods  like  those  of  Eoietzky. 

But  apart  from  this,  lioietzky's  experiments  lose  all  their 
value  when  it  is  realised  that  the  til:)ia  of  the  dog,  which  he 
utilised  in  his  experiments,  contains  grey  and  not  red  marrow. 
Professor  Schiitz  has  shown  that  this  is  true  for  all  breeds  of 
dogs,  and  it  is  further  well  known  thatj  grey  marrow  does  not 
exercise  the  least  haematopoietic  functions. 

This  example,  therefore,  may  be  taken  as  a  strikingly  in- 
structive one,  proving  that  experiments  of  this  kind  cannot  yield 
any  reliable  results. 

Clinical  experience  of  cases,  in  which  considerable  portions  of 
the  bone  marrow  are  replaced  by  other  forms  of  tissue,  supply  far 
more  important  evidence  of  the  functions  of  bone  marrow. 

The  chief  source  of  this  evidence  has  been  obtained  from  cases 
of  carcinosis  of  bone  marrow.  Eeference  has  already  been  made 
to  such  cases.  • 

In  this  affection  large  portions  of  the  bone  marrow  may  be 
replaced  by  tumour  masses ;  under  these  circumstances,  however, 
the  organism  is  capable  of  assisting  itself,  by  giving  rise  to  a 
development  of  myeloid  tissue  in  the  spleen,  lymphatic  glands, 
liver,  etc.,  as  in  embryonal  periods.  But  since  this  form  of 
tissue  is  normally  never  found  in  the  spleen  and  lymphatic 
glands,  the  pathological  appearance  of  myeloid  formation  reveals 


132  ANAEMIA 

with  special  clearness  which  functions  the  bone  marrow  has  to 
perform. 

Bone  marrow  may  be  replaced  by  typical  lymphatic  tissue  as 
well  as  by  the  tissue  of  malignant  growths.  As  Neumann  has 
shown,  and  as  has  since  been  generally  acknowledged,  this  takes 
place  in  lymphatic  leukaemia.  In  cases  of  this  condition  large 
areas  of  bone  marrow  are  occupied,  not  by  malignant  tumour 
masses  but  by  lymphatic  tissue. 

As  a  counterpart  of  this  lymphatic  metamorphosis  of  bone  marrow 
the  myeloid  transformation  of  other  blood-forming  organs  in  myeloid 
leukaemia  may  be  cited.  These  organs  include  more  especially  the 
lymphatic  glands,  and  the  transformation  can  be  recognised  by  the 
presence  of  myelocytes,  eosinophiles,  and  nucleated  red  blood  corpuscles. 

The  substitution  of  myeloid  tissue  in  lymphatic  leukaemia  is, 
it  is  true,  seldom  complete,  and  even  when  it  is  so,  myeloid  tissue 
will  be  seen  to  appear  in  other  blood-forming  organs.  This  is 
the  explanation  why  the  neutrophiles  may  always  be  found,  even 
if  it  be  in  very  small  numbers. 

The  neutrophile  elements  disappear  most  rapidly  in  acute 
lymphatic  leukaemia,  because  the  abnormal  proliferation  takes 
place  with  great  rapidity,  and  for  this  reason  induces  a  quick 
afid  uncomplicated  elimination  of  the  tissue  of  the  bone  marrow, 
as  if  it  had  been  provoked  experimentally.  The  neutrophile 
elements  of  the  marrow  therefore  disappear  rapidly  in  these  cases, 
and  in  some  so  completely  that,  as  in  Ehrlich's  case,  it  may  be 
difficult  to  find  a  single  myelocyte.  The  fact  that  in  this  case 
an  advanced  absolute  diminution  of  the  polynuclear  leucocytes 
in  the  blood  was  met  with,  is  accounted  for  on  the  ground  that 
these  cells  are  derived  from  bone  marrow,  and  consequently,  if  the 
bone  marrow  is  destroyed,  no  more  of  these  cells  could  pass  over 
into  the  blood. 

The  lymphatic  substitution  of  the  marrow  was  more  marked 
still  in  a  case  of  chronic  lymphsemia  observed  by  the  author,  in 
which  death  followed  rapidly  as  a  result  of  sepsis  supervening. 
The  blood  did  not  contain  a  single  neutrophile  cell  among  the 


THE  WHITE  IJLOOI)  COIHMJSCEES     \'.>/.i 

many  thou«aii(l  leucocytes,  luid  in  t.lie  r)r<4-;i,iis  also  not  one  cf^nld 
be  found. 

A  temporary  myelocytosis  of  tli(;  l)lof)(l  ta,k(!H  place  frequently 
in  the  early  stages  of  lymphaemia  as  a  result  of  stimulation  of  the 
bone  marrow.  But  a  continuous  decrease  in  the  numljers  of  the 
myelocytes  in  the  blood  can  be  seen  later,  keeping  pace  with  the 
replacement  of  the  tissue  of  the  medulla. 

The  bone  marrow  has,  as  has  recently  been  determined, 
another  extremely  important  function  besides  that  of  forming 
cells.  This  function  is  the  power  of  producing  antitoxins 
(Wassermann,  Pfeiffer,  and  Marx).  It  therefore  must  be  re- 
garded as  the  organ  par  excellence  which  has  to  decide  the 
teruiination  of  an  acute  infection. 

The  red  blood  corpuscles  are  further  disintegrated  in  the  bone 
marrow,  and  the  available  material  is  utilised  again  for  the  re- 
construction of  new  cells. 


III.— ON  THE  DEMONSTRATION  AND  SIGNIFICANCE  OF 
CELL  GEANULES. 

In  recent  times,  histological,  biological,  and  also  clinical  in- 
vestigation has  aimed,  to  an  ever-increasing  extent  and  with 
most  promising  results,  at  the  solution  of  the  problem  of  the 
significance  of  the  cell  granules.  The  work  undertaken  with 
this  view  has  proved  of  great  importance  to  hfematology,  and 
it  is  now  clear  that  a  number  of  important  questions  wliich 
have  still  to  be  answered  are  intimately  associated  with  the 
study  of  granules.  It  would  therefore  appear  to  be  advisable 
in  this  place  to  deal  with  the  history,  methods,  and  results 
obtained  up  to  the  present  from  the  investigations  concerning 
cell  granules  in  a  comprehensive  manner. 

The  credit  of  having  first  pointed  out  the  great  importance  of 
granules,  and  of  having  obtained  practical  results  by  systematic 
long-continued  investigations  of  this  subject,  undoubtedly  belongs 
to  Ehrlich.  It  seems  necessary  to  emphasise  this  fact,  as  Altmann 
has  repeatedly  maintained  that  it  is  not  the  case,  in  spite  of  the 


134     '  ANEMIA 

fact  that  his  attention  has  been  called  to  the  real  state  of  affairs. 
After  Ehrlich  replied  to  Altmann's  priority  claim  in  a  special 
article  in  1891,^  Altmann  stated  in  the  second  edition  of  his 
Elementarorganisme7i,  which  was  published  in  1894,  that  he  was 
the  first  to  recognise  the  specific  importance  of  the  granules, 
and  that  although  these  bodies  had  been  observed  by  a  few 
authors,  they  had  only  been  regarded  as  "  specialities  and 
isolated  appearances."  It  is  therefore  necessary  to  quote  a  few 
pregnant  passages  from  Ehrlich's  work. 

It  is  quite  clear  that  Ehrlich  did  not  regard  the  granules  as 
"isolated  appearances"  in  one  of  his  earliest  publications  on 
this  subject,  which  appeared  in  1878,  that  is,  ten  years  before 
Altmann's  contributions.  It  must  be  admitted  that  an  author 
who  devotes  ten  years'  work  almost  exclusively  to  a  single  subject 
could  not  but  regard  the  subject  of  his  investigations  as  of 
considerable  biological  importance. 

In  respect  to  this  matter,  Ehrlich  wrote  :  "  The  word  '  granu- 
lated'has  been  employed  with  predilection  since  the  beginning 
of  histology  to  indicate  a  constitution  of  cellular  structures 
The  choice  of  this  expression  is  not  a  very  happy  one,  since  very 
many  circumstances  may  lend  the  appearance  of  granulation  to 
protoplasm.  Modern  methods  of  examination  have  shown  that 
many  elements  which  were  described  by  earlier  authors  as  granu- 
lated owe  this  impression  to  the  presence  of  a  reticulated 
superimposed  protoplasmic  network.  These  cells  are  just  as  little 
granulated  as  are  cells  which  show  granulated  albumin  precipita- 
tion resulting  from  cadaveric  coagulation  or  from  the  influence  of 
certain  chemical  reagents  such  as  alcohol.  The  term  should 
therefore  be  reserved  for  the  elements,  which  include  substances 
in  granular  form  during  life,  that  can  be  distinguished  by  chemical 
means  from  the  normal  albuminous  substances  of  the  cells. 
Only  a  few  of  these  granulations,  like  fat  and  pigment,  are  easily 
recognisable ;  the  majority  cannot  be  characterised,  or  can  only  be 
indistinctly  characterised  with  the  help  of   the  methods   now  in 

^  See    Ehrlich,     Farhenanalytische   UntersucJningen   XII,,    zur    GescMdtte    der 
Granula,  p.  134. 


THE   WHITE   IJLOOI)  (OIMM JSCIJIS      i;jV 

general  use.  It  used  to  be  cou8i(l(!i(;<l  siiCliciciit  to  (letcnuine  the 
presence  of  granules  in  certain  colls,  and  according  to  whetlier 
they  refracted  light  or  not,  to  register  them  as  either  fat  or  albumin 
granules. 

"  Previous  experience,  especially  in  connection  with  mast  cells, 
has  induced  me  to  expect  that  the  characteristics  of  these 
granules,  which  have  so  long  resisted  chemical  examination,  might 
appear  sufficiently  sharp,  Ity  means  of  colour  anal}'sis,  i.e.,  by 
means  of  their  behaviour  to  certain  staining  agents.  As  a  matter 
of  fact,  I  have  found  these  forms  of  granules,  which  could  be 
recognised  by  their  elective  attraction  for  certain  dyes,  and  which 
can  therefore  be  readily  traced  through  series  of  animals  and  of 
organs.  I  have  further  been  able  to  prove  that  certain  kinds  of 
granulation,  which  I  have  discovered,  are  only  found  in  certain 
cellular  elements.  These  granules  characterise  the  cells  in  the 
same  way  as  pigment  characterises  the  pigment  cells,  and  gly- 
cogen the  cartilage  cells  (Neumann),  etc.  Just  as  the  diagnosis 
of  the  mast  cells,  which  show  so  many  variations,  can  only  be 
made  from  the  granulation  which  stains  with  dahlia,  i.e.  from  the 
result  of  a  chemical  reaction,  other  granulated  cells,  which  cannot 
be  distinguished  from  one  another  morphologically,  can  readily  be 
classified  into  definite  sub-groups  on  the  basis  of  their  tinctorial 
behaviour.  In  consideration  of  these  differentiating  characteristics 
I  would  propose  to  call  such  granulation  '  specific  granulations.' 

"  The  examination  was  carried  out  by  Koch's  method  of  pre- 
paring very  thin  smears  of  the  fluids  (blood)  or  the  parenchyma 
of  the  organs  (bone  marrow,  spleen,  etc.)  on  cover-slips,  allowing 
these  smears  to  dry  at  room  temperature,  and  then  staining  them 
after  varying  intervals.  I  chose  this  apparently  somewhat  rough 
method  more  especially  because,  for  the  histological  detection  of 
new  granules  which  may  possibly  correspond  to  definite  chemical 
compounds,  it  was  necessary  to  avoid  using  any  substances  which, 
like  water  or  alcohol,  might  act  as  solvents  or,  like  osmic  acid,  etc., 
as  oxydising  agents.  To  gain  this  end,  only  methods  of  pro- 
cedure like  simple  drying  would  preserve  the  chemical  individuality 
as  little  changed  as  possible." 


136  ANEMIA 

Further  advance  in  this  extremely  complicated  section  of 
histology,  however,  was  only  rendered  possible  by  an  exact  study 
of  staining  processes,  and  of  the  relations  which  exist  between 
chemical  constitution  and  staining  characteristics.  The  first 
result  of  this  investigation  which  no  one  had  ever  undertaken 
before  was  the  sharp  definition  of  acid,  basic  and  neutral  dyes,  and 
of  the  corresponding  oxy-,  baso-,  and  neutrophile  granules.  It 
was  only  possible  after  experimenting  with  many  hundred  com- 
binations to  discover  the  triacid  solution,  which  has  played  a 
highly  valuable  role  in  the  demonstration  of  the  most  important 
phenomena. 

The  classification  of  the  cell  granules  in  the  blood,  constructed 
with  the  assistance  of  these  methods  according  to  their  varying 
chemical  affinities,  is  still  accepted  as  the  best  and  indeed  as  the 
only  useful  method  of  grouping  the  leucocytes.  Ehrlich  laid 
special  stress  from  the  first  on  the  fact  that  various  forms  of  cells 
included  various  forms  of  granules,  which  could  be  distinguished 
from  one  another,  not  only  by  their  tinctorial  behaviour,  but  also 
by  the  special  way  in  which  they  responded  to  various  solvents. 

Altmann's  method,  which  depends  on  a  complicated  fixation 
process  and  a  single  unvarying  method  of  staining,  must  be 
regarded  as  retrograde  from  this  point  of  view,  since  it  is  likely 
to  obscure  the  principle  of  the  specific  character  of  each  type  of 
granulation. 

Another  disadvantage  of  Altmann's  method  of  hardening 
consists  in  the  fact  that  it  precipitates  albuminous  substances 
included  in  the  cells  in  the  form  of  round  grains  which  take  on 
stain  like  real  granules.  In  this  way  it  becomes  extremely  difficult 
to  distinguish  preformed  from  artificial  elements.  Since  A.  Fischer's 
publication,  in  which  he  demonstrated  the  experimental  production 
of  granule-like  artefacts  by  various  reagents,  many  authors  have 
recognised  that  there  are  grave  doubts  as  to  the  reality  of  Alt- 
mann's granules.  In  contrast  to  this,  Ehrlich's  dry  method  has 
been  shown  to  be  quite  free  from  objection.  Granules  cannot  be 
produced  artificially  by  drying,  and  what  is  seen  in  the  stained 
specimens   corresponds   exactly  to  what  is   seen  in  fresh  living 


THE  WHITE  Hr.OOl)  COIllMJSCLKS     \'M 

blood.  Tlio  chief  value,  however,  of  tlie  dry  method  is,  that  the 
chemical  iiulividuality  of  the  variouH  graruihis  remains  quite  un- 
altered, HO  that  all  the  chemical  dillerential  e^^periments  take 
place  in  an  object  which  i.s  ])ractically  intact.'^ 

A  farther  manner  of  gaining  an  insight  into  the  nature  of  tlie 
granules  depends  on  the  principle  of  vital  staining.  The  first 
attempt  to  stain  granules  in  living  animals  was  stimulated  by 
Ehrlich's  vital  nictliylonc-l)luo  staining,  the  practical  importance 
of  which  to  neurology  has  been  universally  recognised.  One  of 
the  earliest  publications  on  this  subject  was  that  of  0.  Schultze, 
who  immersed  frog  larvae  in  dilute  methylene-blue  solutions  and 
after  a  short  time  found  a  blue  staining  of  the  granules,  especially 
of  the  intestines,  of  the  red  blood  corpuscles  and  of  other  kinds  of 
cells.  This  method,  however,  as  Ehrlich  has  experienced  on  many 
occasions  in  his  methylene-blue  studies,  is  not  quite  free  from 
objection,  since  methylene-blue,  after  it  lias  1  )een  used  for  some  time, 
frequently  forms  granular  precipitates  which  can  be  confused  with 
granules.  Teichmanu  deals  with  this  point  in  an  exhaustive  dis- 
cussion, and  considered  that  the  majority  of  the  granules  which 
Schultze  described  are  artificial  productions. 

Neutral  red,  which  was  first  recommended  for  this  purpose  by 
Ehrlich,  and  which  has  since  been  employed  successfully  by  Przes- 
mycki,  Prowazek,  S.  Mayer,  Pappenheim,  and  others,  is  highly 
suitable  for  the  study  of  vital  staining  of  granules.  This  dye  was 
compounded  by  0.  JST.  Witt  out  of  nitroso-dimethyl-anilin  and 
meta-toluylen-diamin.  It  is  the  chloride  of  the  basic  dye,  and  is 
soluble  in  pure  w^ater,  forming  a  fuchsin-coloured  solution.  In 
solution  in  weak  alkaline  fluid  (the  alkalinity  of  spring  water  is 
sufficient  for  this  purpose)  the  dye  takes  on  a  yellowish-orange 
colour. 

jSTeutral  red  has  a  special  characteristic  in  that  it  possesses  an 
almost  maximal  affinity  for  the  majority  of  granules.  Ehrlich 
was  able  to  demonstrate  the  presence  of  granules  even  in  some 

^  Altmanu's  freezing  process  would  coi-respoud  to  the  conditions  -wliicli  Ebrlicli 
ha-i  always  insisted  u[)on.  But  it  presents  suck  great  technical  difficulties  that  up 
to  the  present  it  has  not  found  acceptance. 


138  ANiEMIA 

plant  cells  by  means  of  this  dye.  The  method  of  application  is 
extremely  simple.  In  the  higher  animals  numerous  granules  can 
be  stained  by  subcutaneous  or  intravenous  injection  or  even  by 
feeding.  Frog  larvse  and  mollusca  may  be  sufficiently  stained,  if 
they  are  allowed  to  swim  about  in  dilute  solutions  of  the  dye. 
Even  in  "surviving"  (Uherlehende)  organs  the  staining  may  be 
successful.  It  is  best  carried  out  by  allowing  small  portions  to  float 
about  for  a  time  in  physiological  salt  solution  to  which  a  trace  of 
neutral  red  has  been  added,  with  free  access  of  air.  As  soon  as  the 
object  appears  red  to  the  naked  eye  it  is  ready  for  examination. 

As  might  have  been  expected,  the  most  beautiful  results  are 
obtained  with  organs  which  can  be  easily  teased  out,  such  as  the 
eggs  of  flies,  the  Malpighian  canals  of  insects,  etc.  The  solution 
of  the  stain  should  be  so  prepared  that  the  act  of  staining 
does  not  take  too  long,  but,  on  the  other  hand,  that  the  concen- 
tration of  the  dye  is  not  so  high  that  the  nucleus  of  the  cell 
takes  any  of  it  up.  One  part  in  50,000  to  one  part  in  100,000 
suffices  as  a  rule  for  this  purpose.  The  hsematologist  tries  to 
prepare  films  in  which  only  the  granules  of  the  cell  are  stained, 
while  the  protoplasm  and  nucleus  appear  unstained.  Artificial 
productions  cannot  be  entirely  excluded  even  with  this  method. 
In  cells  of  plants  which  contain  tannin  the  production  and 
precipitation  of  tannates  of  the  dye  may  simulate  granules.  It 
is,  however,  not  difficult  for  an  experienced  observer  to  recognise 
these  artificial  products  as  such.  The  kind  of  granulation,  their 
typical  distribution,  a  comparison  with  neighbouring  cells,  the 
combination  of  various  methods,  a  comparison  of  the  same  object 
stained  with  vital  staining  and  with  "  surviving "'  staining,  all 
contribute  toward  making  it'easy  to  form  a  proper  opinion  with 
regard  to  the  granules,  and  to  pro'tect  the  observer  from  making 
mistakes. 

The  majority  of  the  granules  in  vertebrates  are  stained 
orange  red,  in  accordance  with  the  mildly  alkaline  condition  of 
these  structures.  Grains  which  stain  a  pure  fuchsin  colour  are 
met  with  much  less  frequently,  and  these  must  accordingly  have  a 
weak  acid  reaction. 


THE   WHTTK   IJLOOI)  CORIMTSCLKS     139 

Combined  method.s  of  Hlaiiiiiiii,-  ciiii  ho  u.sed  ;ih  valuable 
auxiliaries  to  neutral  red  staining-.  l^^brli(;h  (;ii)])loyed  a  double 
staining  with  neutral  red  and  ii)(;ihylei)(j-ljluo,  by  immerHing 
frosr's  larva  in  a  solution  oi'  nciutral  rc^d  to  wliicb  a  trace  of 
methylene-blue  had  ])een  added.  lie  fouml  the  granulation 
almost  exclusively  red,  but  that  of  unstri^ted  intestinal  muscle 
was  stained  an  intense  l)lue.  He  further  obtained  a  still  more 
marked  dillerentiation  of  living  cell  granules  Ijy  means  of 
a  triple  combination.  There  is  no  doubt  that  a  careful  study 
of  the  neutral  red  methods  will  bring  to  light  further  important 
details  in  respect  to  the  nature  and  function  of  granules,  and 
will  illuminate  some  of  the  most  delicate  problems  of  cell  life. 
The  knowledge  which  has  already  been  acquired  admits  of 
definite  conceptions  of  the  biological  significance  of  the  cell 
granules. 

A  number  of  interesting  finds  have  been  recorded  during 
recent  times  as  a  result  of  studies  wdth  vital  staining  by 
Arnold,  Eosin  and  Bibergeil,  Pappenheim,  and  others. 

Ehrlich  described  the  granules  as  metabolic  products  of  the 
cells  in  his  first  publication.  He  believed  that  these  products 
were  deposited  in  solid  form  in  the  protoplasm,  to  serve  partly 
as  reserve  material  and  partly  to  be  cast  out  of  the  cell. 
He  only  departed  from  this  view  for  a  short  time  when  he 
came  to  consider  the  observations  made  with  liver  cells,  which 
have  been  exhaustively  described  in  Frerich's  well-known  work 
(1883,  p.  43).  Ehrlich  showed  that  the  liver  cells  in  dry 
specimens  of  rabbit's  liver,  which  is  rich  in  glycogen,  appear  as 
voluminous,  polygonal  elements  with  symmetrical,  homogeneous 
brown  colour,  limited  externally  by  a  narrow,  sharply  defined 
pure  yellow  membrane.  It  could  be  seen  that  the  cells  which 
did  not  contain  much  glycogen,  contained  in  the  homogeneous 
glycogen-brown  content  small  rounded  pure  yellow  particles 
which  were  obviously  of  a  protoplasmic  nature.  "  The  application 
of  dyes  revealed  that  the  hyaline,  glycogen-carrying  substance 
fdling  the  cell  was  not  stainable  under  any  circumstances,  while 
the  membrane  and  the  granules,  which  are  present  in  the  cells. 


140  ANJEMIA. 

stain  readily  with  almost  any  dye.  It  was  further  possible  to 
demonstrate,  by  means  of  dyes,  that  the  membrane  is  chemically 
different  from  the  granules,  since  when  eosin-aurantia-indulin- 
glycerine  is  employed,  the  membrane  colours  blackish  and  the 
granules  a  reddish  orange." 

From  these  observations  Ehrlich  deduced  the  following  con- 
clusions, which  may  be  quoted  literally :  "  That  the  cells  of  the 
liver  during  the  period  of  feeding  contain  a  narrow  protoplasmic 
membrane  and  a  homogeneous  content  which  carries  glycogen, 
and  in  which  the  nucleus  and  the  round  granules  of  (functionat- 
ing) protoplasm  are  embedded. 

When  these  results  are  compared  with  the  knowledge  which 
has  been  gained  within  recent  times  with  regard  to  cells  it  becomes 
easy  to  determine  the  exact  position  where  the  glycogen  is 
deposited.  Kupffer  first  established  the  fact  with  regard  to  liver 
cells,  that  the  contents  of  the  cell  do  not  represent  a  uniform  body 
microscopically.  This  has  proved  to  be  true  for  all  cells.  In  the 
"  surviving "  object,  two  distinctly  different  substances  are  found 
beside  the  nucleus ;  the  one,  a  hyaline  matrix,  which  constitutes  the 
greater  part  of  the  mass,  and  the  other,  a  sparse  finely  granulated 
fibrillary  substance,  which  is  embedded  in  the  former.  Kupffer 
called  the  former  paraplasm  and  the  latter  protoplasm.  By 
warming  the  objects  to  about  22°  C.  a  distinct  but  slight 
movement  w^as  observed  in  the  network.  There  can  be  no  doubt 
but  that  of  these  two  substances,  the  granulated  reticulated 
one — the  protoplasm — is  the  more  important.  It  may  be  assumed 
that  the  granulation  of  the  network  is  the  centre  of  the  real 
specific  function  of  the  cell.  Any  way,  it  will  be  advisable  to 
give  a  special  name,  such  as  microsomes,  to  these  structures, 
which  in  the  liver  cell  form  round  or  oval  granules  staining 
yellow  with  iodine,  and  taking  on  other  dyes  easily  and 
intensely  (Hanstein)." 

It  was  necessary  to  quote  this  old  work  extensively  to  show 
that  Ehrlich  had,  even  as  long  ago  as  1883,  described  the 
granules  as  the  actual  carriers  of  the  function  of  the  cell ;  this 
view   was   enunciated   many  years  later  by  Altmann  under  the 


THE  WHITE  HLOOl)  CORPUSCLES     141 

name  "  hioblast  theory."  Conse(niently  the  fore^^oin^^  may  he 
coiiHulered  to  bo  ample  evidciu-e  that  Altmann'H  repeated  elaim, 
that  no  one  liad  accorded  a  lull  si^iiilifaiifc  to  Liu;  granules 
prior  to  him,  is  absolutely  untenable. 

The  following  quotation  from  Altmann'w  work  (Die 
Elcmcntaroryanismen,  1st  Ed.,  p.  '^^■))  shows  what  significance 
he  ascribed  to  those  granules  wlii(;li  lie  termed  "  ozoiiophore.s." 

"The  term  ozonophore  is  intended  to  convey  the  special 
idea,  which  is  calculated  to  take  the  place  of  the  older  con- 
ception of  living  protoplasm,  at  all  events  as  far  as  its 
vegetative  function  is  concerned,  and  which  is  capable  of  serving 
as  a  basis  for  the  varied  processes  of  organic  metabolism. 
To  recapitulate  the  capabilities  of  the  ozonophores,  it  may  be 
said  that  they  perform  reducing  as  well  as  oxydising  functions, 
by  the  transport  of  oxygen,  and  thus  cause  the  disintegration  and 
synthetic  construction  of  bodies,  without  losing  their  own 
individuality  in  the  least  degree." 

In    the    meantime    Ehrlich  has    made    several    observations 
which   cannot   be  reconciled  with    his    own   earlier   hypotheses, 
and  with  Altmann's  far-reaching  deductions.     His  investigations 
with  regard  to  the  oxygen  requirements  of  the  organism  had  taught 
him  that  "  ozonophores  "  cannot  possibly  be  integral  constituents 
of  the  cells.     The  fact  that  there  are  normal  cells  in  which  no 
granules  can  be  detected  by  any  of   the  ordinary  methods   had 
also  to  be  taken  into  account.     Finally,  a  pathological  observation 
showed    that    it    is    impossible   to   defend   the   view   that    the 
o-ranules   are  the  carriers   of   the    cell    function.     It    has    been 
shown  in  fishes  and   in   other   lower  animals  that  the    granules 
can  be  made   to    disappear    experimentally    by   starvation.      In 
the   examination  of   a  case   of   pernicious    anemia  (see  Farhen- 
analytischc   Untcrmcliungcn)  Ehrlich  found  that  the  poly  nuclear 
cells  of  the   blood   and    of    the    bone    marrow,    and    also    their 
precursors,  were  free  from   neutrophile  granulation.      This  find 
caused  him  to  return  to  his  older  view,  that  the   granules  were 
the  secretion  products  of  the  cells,  and  he  expressed  his  opinion 
in  the  following  words  : — 


142  ANJEMIA 

"  If  the  neutrophile  granules  were  really,  as  Altmann 
supposes,  elements  which  supply  the  cell  with  oxygen,  the  con- 
dition which  I  have  just  described  would  be  excluded,  since  the 
disappearance  of  the  granules  would  produce  the  death  of  the 
cell.  The  conditions  described,  however,  can  easily  be  explained 
on  the  basis  of  the  secretion  theory,  just  as  this  theory  could 
explain  how  a  fat  cell  can  lose  its  contents  completely  without 
dying.  The  same  applies  to  the  bone  marrow  cell  when  the 
blood  fails  to  supply  the  necessary  precursors,  under  which 
circumstances  it  cannot  form  any  further  neutrophile  granules, 
and  must  therefore  be  transformed  into  non-granulated  cells." 

The  great  chemical  differences  between  the  various  forms  of 
granules  may  be  regarded  as  evidence  in  favour  of  the  view  that 
the  granules  are  actually  the  metabolic  products  of  the  specific 
activity  of  the  cells.  Ehrlich  has  paid  special  attention  to 
these  conditions  in  the  blood,  and  has  found  that  the  granules  in 
the  blood  cells  not  only  differ  from  one  another  with  regard 
to  staining  reactions,  but  also  with  regard  to  shape  and 
solubility.  It  was  therefore  necessary  to  draw  sharp  lines  of 
demarcation  between  the  various  kinds. 

It  can  be  shown  that  while  the  majority  of  the  granules  are 
more  or  less  round  structures,  in  some  animal  species,  e.g.  in  birds, 
analogies  to  the  granules  of  the  mammal's  blood  are  met  with 
which  are  characterised  by  a  well-marked  crystal  form  and 
decided  oxyphilic  qualities.  The  substance  contained  in  the  mast 
cell  granules  occurs  in  some  species  of  animal  in  a  pure  crystalline 
form. 

The  size  of  the  individual  grains  in  the  blood  cells  of  each 
species  of  animal  is  a  definite  one  for  each  kind  of  specific 
granulation.  The  mast  cells  alone  form  an  exception  to  this 
rule.  The  eosinophile  granules,  for  example,  reach  their  maximum 
in  the  horse,  where  they  assume  giant  proportions. 

The  occurrence  of  granulated  colourless  blood  cells  has  been 
demonstrated  in  practically  every  species  of  animal.  This  has 
been  emphasised  by  Knoll,  who  found  that  it  obtained  even 
in    the    case    of    many   invertebrates,   more    especially   in    the 


THE   WIIITK  lU.OOD  COllinJSCI.ES     143 

lainellibi'aiicliiaioH,  polyclijoto.s,    [kji lutes,   tuiiicat(;.s,  and    (■.(;j)lialo- 
pods. 

Exact  and  inunor()iis  (;xa,iiiiii;i,ti(»iis  in  this  icL'iiid  liavo  hocii  ron- 
ducted  with  the  blood  of  the  vertebrates,  and  especially  the  hjf^her 
forms.  For  example,  two  forms  of  oxy])hile  granulation  a,re 
known  in  birds,  of  which  one  kind  of  granule  is  embedded  in  ifjr; 
cell  in  crystal  form  and  the  otliei'  in  the  ordinary  L>i-;iin  form. 
The  majority  of  the  mammals  whose  blood  has  Ijeen  examined 
possesses  granulated  polynuclear  cells.  Hirschfeld  lias  dealt  with 
this  subject  in  an  exhaustive  work,  in  which  a  large  nundjer  of 
very  remarkable  details  are  contained.  He  found  that  in  the 
majority  of  the  animals  examined  the  polyrmclear  cells  were 
provided  with  neutrophile  granules,  and  only  in  one  animal,  the 
white  mouse,  did  he  fail  to  find  this  or  an  analogous  form  of 
granulation. 

The  statements  made  by  Hirschfeld  cannot  be  accepted,  in 
view  of  some  investigations  undertaken  by  Dr.  Franz  Miiller  in 
Ehrlich's  laboratory.  After  many  fruitless  attempts  Dr.  Miiller 
discovered  a  method  by  means  of  which  he  was  able  to  demon- 
strate numerous  but  extremely  fine  granules  in  the  polynuclear 
cells  of  the  mouse.  This  shows  that  it  is  not  permissible  to 
assume  the  absence  of  granules,  even  if  the  ordinary  staining 
methods  do  not  suffice  to  reveal  any.  Just  as  there  is  no 
universal  method  of  demonstrating  bacteria,  so  there  is  none  for 
rendering  granules  visible.  All  the  granules  which  consist  of 
soluble  substances  must  necessarily  disappear  when  the  ordinary 
triacid  method  is  employed,  thus  simulating  a  homogeneous  cell 
protoplasm. 

The  foregoing,  however,  is  not  intended  to  indicate  that  the 
occurrence  of  non-granulated  polynuclear  cells  is  denied  in 
certain  animal  species.  Hirschfeld  states  that  such  cells  exist 
side  by  side  wdth  granulated  cells — for  example,  in  the  dog,  and 
from  this  find  he  deduces  far-reaching  conclusions  with  regard 
to  the  significance  of  the  granules.  It  must,  however,  be  pointed 
out  that  Kurloff's  work  tends  to  show  that  there  is  no  reason 
for    assuming    that    the    non-granulated    polynuclear    cells    are 


144  ANEMIA 

identical  with  the  granulated  cells.  Kurloff  was  able,  at  all 
events  as  far  as  the  blood  of  the  guinea-pig  is  concerned,  to 
prove  that,  these  two  different  elements  may  be  sharply  dis- 
tinguished from  one  another  and  that  they  each  have  a  separate 
genesis. 

The  fact  that  in  general  only  those  cells  of  the  blood  which 
are  meant  for  migration  and  chemotaxis,  and  which  are  capable 
of  carrying  out  these  functions,  contain  granules  must  be  regarded 
as  highly  important.  This  applies  to  all  species  of  animals.  It 
is  a  very  suggestive  assumption,  which  can  scarcely  be  disproved, 
that  the  migration  of  the  granulated  cells  has  a  certain  degree 
of  nutritive  character,  and  for  this  purpose  just  those  cells 
which  enclose  abundant  quantities  of  reserve  material  would  be 
peculiarly  adapted.  On  the  other  hand,  the  lymphocytes  do  not 
contain  the  kind  of  granulation  met  with  in  the  myeloid  cells, 
nor  are  they  involved  in  the  chemotactic  process. 

A  further  indication  that  the  granulation  actually  is  coimected 
with  a  specific  activity  of  the  cells  is  found  in  the  fact  that  one 
cell  is  the  carrier  of  only  one  specific  kind  of  granule.  Ehrlich 
was  able,  on  the  basis  of  investigations  undertaken  specially  to 
clear  up  this  point,  to  show  that  the  contrary  opinion,  which 
recognised  the  simultaneous  occurrence  of  neutrophile  and  eosino- 
phile  granulation  or  of  eosinophiie  and  mast  cell  granulation  in 
one  and  the  same  cell,  was  not  in  correspondence  with  fact. 
This  contention  has  been  fully  confirmed  during  the  past  ten 
years  in  an  almost  innumerable  series  of  control  experiments. 
The  author,  who  has  carried  out  an  extraordinarily  large  number 
of  examinations  has  never  met  with  the  combination  in  question 
even  when  the  most  severe  pathological  conditions  have  existed, 
either  in  the  blood  or  in  the  blood-forming  organs.  Ehrlich 
has  never  observed  the  alleged  transformation  of  the  pseudo- 
eosinophile  cell  of  the  rabbit  into  the  true  eosinophile  cell.^ 

^The  cause  of  this  kind  of  misiinclerstanding  is  to  be  sought  in  the  develop- 
mental stages  of  the  granules,  when  the  tinctorial  characters  show  variations,  as 
has  been  described  at  some  length  on  a  preceding  page.  How  little  tinctorial 
variations  alone  suffice  to  determine  the  chemical  identity  of  granules  becomes  quite 
clear  when  the  granules  of  other  organs  are  taken  into  consideration.    No  one  would 


THE  WHITE  IJLOOD  CORPUSCLES     J 45 

With  regard  to  the  transformation  in  tho  rabhit,  it  may  be 
stated  that  the  best  method  of  proviii<r  tliat  this  does  not  take 
place  is  by  iitihsiii*^  tlic  fii,c-t  that  the  diffeicMit  granules  behave 
did'erently  towards  the  various  solvents.  Yov  example,  the  pseudo- 
eosinophile  granules  can  be  completely  extracted  from  the  cells 
by  acids,  while  the  eosinophile  granules  are  left  intact  by  this 
procedure  and  can  then  be  stained  alone. 

The  most  convincing  proof  that  the  neutrophile,  eosinophile, 
and  mast  cells  are  absolutely  differentiated  from  one  another  by 
the  original  differences  of  the  protoplasm,  of  which  the  granula- 
tion is  but  one,  albeit  a  peculiarly  striking,  cliaracter,  is  found 
in  the  study  of  the  various  forms  of  leucocytes.  As  will  be 
proved  in  detail  in  the  following  chapter,  the  neutrophile  and  the 
eosinophile  leucocytes  behave  quite  differently  as  regards  their 
chemotactic  susceptibility  to  stimulation.  Those  substances  which 
call  forth  either  a  positive  or  a  negative  energetic  chemotaxis  in 
one  group  of  cells  fail  to  exert  any  influence  on  another  group. 
At  times  even  an  opposite  effect  is  noted,  in  that  a  substance 
produces  an  attraction  for  one  kind  of  cell  and  a  repulsion  for 
another  kind.  The  behaviour  of  the  mast  cells  in  this  respect 
show^s  a  still. more  striking  difference.  As  far  as  the  subject 
has  been  investigated,  those  substances  which  exert  a  chemotactic 
effect  on  the  neutrophile  or  eosinophile  cells  do  not  influence 
the  mast  cells  at  all. 

In  accordance  with  the  characters  of  the  granules  as  specific 
cell  secretions,  the  various  kinds  ought  to  be  differentiable  in  so 
far  as  their  chemical  peculiarities  are  concerned.  The  granules 
of  the  blood  corpuscles  appear  to  possess  a  relatively  simple 
chemical   composition.      There    is    reason    to    believe   that   the 

ever  dream  of  asserting  that  a  liver,  muscle,  or  brain  cell  could  secrete  pancreatia 
simply  because  the  granules  of  the  pancreas  as  demonstrated  by  the  various 
staining  methods  showed  the  same  staining  characteristics  as  those  of  the  above- 
mentioned  cells.  The  author  wishes  to  state  most  emphaticall}^  that  he  is  only 
prepared  to  recognise  a  uniform  character  of  each  kind  of  granulation  to  the 
full  extent  when  this  applies  to  the  blood  cells,  in  which  the  granules  have  a 
comparatively  simple  function,  and  that  the  highly  complicated  glandular  cells, 
which  must  perform  several  functions  simultaneously,  may  include  sevei'al  kinds  of 
granules. 


146  ANJEMIA 

crystalline  granules  consist  chiefly  of  one  single  chemical  com- 
pound, which  need  not  even  be  highly  organised  and  which,  like 
guanin,  fat,  melanin,  etc.,  seems  to  be  a  relatively  simple  substance. 
The  other  forms  of  granules  no  doubt  have  a  more  complex 
composition  and  are  probably  mixtures  of  chemically  separate 
substances.  The  most  complicated  granules  of  the  blood  are  the 
eosinophilic,  which,  as  has  already  been  pointed  out,  possess  a 
higher  histological  structure,  including  a  peripheral  layer  which  can 
be  distinctly  distinguished  from  the  central  portion  of  the  granule. 

It  is  quite  probable  that  the  granules  are  gradually  given  off 
to  the  neighbouring  tissue.  It  is  true  that  proof  of  this  is 
extremely  difficult  to  produce,  aud  much  of  what  has  in  the  past 
been  regarded  as  evidence  for  this  elimination  has  turned  out  to 
be  erroneous.  An  example  of  this  is  the  so-called  areola  of  the 
mast  cells.  In  the  case  of  the  mast  cell  areola,  it  is  fairly 
evident  that  in  the  specimens  the  granulations  which  are  ex- 
tremely soluble  in  water  were  not  sufficiently  fixed. 

On  the  other  hand,  it  is  by  no  means  diificult  to  demonstrate 
in  old  pus  a  rarefication  of  the  polymorph o-nuclear  neutrophile 
granules,  which  may  be  almost  complete.  All  other  explanations, 
save  that  of  the  casting  off  of  the  granules  into  the  surrounding 
tissue,  would  appear  to  be  unsatisfactory  in  this  case. 

IV.— THE  DUALISTIC  DOCTEINE 

It  may  be  said  that  at  the  present  time  there  is  no  longer 
any  really  earnest  opposition  to  Ehrlich's  doctrine  of  the 
specificity  of  the  granulations  and  of  the  formed  mature  types 
of  leucocytes.  This  doctrine  may  therefore  be  recorded  as  a 
definite  fact.  But  an  energetic  struggle  still  exists  with  regard 
to  the  further  question,  as  to  whether  a  sharp  division  should 
be  drawn  between  the  lymphatic  and  the  myeloid  systems  and 
between  the  cells  which  are  derived  from  these  two  tissues. 
Ehrlich  has  enunciated  this  dualistic  doctrine  as  the  most 
important  result  of  his  long-continued  studies.  A  large  number 
of  opponents  have  disputed  the  correctness  of  this  view,  among 


THE  WHITE  IJLOOI)  C:OUJHJSCLKS     147 

jvhom  Arnold,  Neumann,  May,  (Irawit/J,  Alaxiniow,  Woidenreicli, 
Hirsclit'eld,  and  l'ap])enliciin  may  be  named;  while  the  most 
energetic  supporters  of  his  teaching  are  Banti,  Tiirk,  Steniherg, 
Holly,  Schridde,  Erich  Meyer,  K.  Ziogler,  Naegeli,  and  oLhois. 

Tlie  disputed  question  may  be  expressed  as  follows:  (Jan, 
under  given  conditions,  myeloid-tissue  formation  as  well  as 
lymphatic  formations  arise  post-embryonally  from  lympho- 
cytes? Some  opponents  of  the  dualistic  docLriiie  maintain  that 
the  ordinary  mature  blood  lymphocytes  possess  the  capability 
of  transforming  themselves  at  will  into  any  other  form  of  cell 
(Grawitz),     This  view,  however,  is  no  longer  tenable. 

The  possibility  that  you,ng  still  immature  organ  cells  having 
the  histological  characters  of  lymphocytes  may  take  on  a 
different  development  in  the  blood-forming  organs  is  a  more 
reasonable  one.  The  supporters  of  this  view  regard  the  non- 
granulated  cells  of  the  myeloid  tissue  without  further  ado  as 
lymphocytes ;  but  in  the  opinion  of  the  author,  there  are  con- 
vincing arguments  against  such  an  assumption,  as  has  already 
been  stated. 

If  all  the  arguments  for  and  against  the  dualistic  doctrine 
be  reviewed  it  must  be  admitted  that  the  past  few  years  have 
brought  some  very  important  facts  which  speak  in  favour  of 
this  doctrine.  The  embryological,  histological,  biological,  and 
clinical  experience  in  particular  have  forced  the  htematologist 
to  a  very  definite  conclusion  which  can  only  be  expressed  as 
follows:  Ehrlich's  dualism — the  ingenious  idea  of  the  creator 
of  ha?matology,  has  been  definitely  proved  as  correct.  Those 
opponents  who  refuse  to  agree  with  this  conclusion  must  be 
prepared  to  be  reproached  with  a  limited  knowledge  of  histologv, 
and  with  the  statement  that  they  have  not  studied  the  whole 
problem  with  sufficiently  fine  histological  methods,  e.g.  section 
staining,  and  that  they  have  not  penetrated  deeply  enough 
into  the  cytological  aspect  of  the  question.  The  most  solid 
support  of  medical  science — pathological  anatomy — has  spoken 
the  decisive  word,  but  not,  it  is  true,  until  a  most  intricate 
technique  had  been  requisitioned. 


148  ANtEMIA 

The  author  has  been  able  to  show  by  embryological  investiga.- 
tions  that  the  myeloid  system  first  develops,  and  that  much 
later,  and  as  an  absolutely  separate  phenomenon,  the  lymphatic 
system  follows.  In  view  of  this  find,  the  idea  which  had  been 
expressed  over  and  over  again,  that  myeloid  tissue  is  only  a 
more  highly  developed  form  of  lymphatic  tissue,  must  fall  to 
the  ground. 

What  do  the  opponents  of  the  dualistic  doctrine  say  to  meet  this 
argument  1  They  maintain,  without  producing  any  histological  evidence, 
that  lymphatic  tissue  is  more  highly  developed  myeloid  tissue  ! 

The  finer  histological  researches  have  shown  that  in  adult 
life  these  two  systems  never  transcend  from  one  to  the  other, 
but  that  they  actually  stand  in  opposition  to  one  another. 
Under  no  circumstances  has  it  been  proved  that  the  germinal 
centre,  for  example,  of  the  lymph  follicles  can  act  as  the  site  of 
origin  of  myeloid  cells.  More  than  this,  E.  Meyer  and  Heineke, 
Naegeli,  Ziegler,  Schridde,  and  others  have  observed  that  myeloid 
proliferation  always  appears  independently,  and  perhaps  adventi- 
tiously, replacing  the  lymphatic  tissue  and  gradually  substituting 
it.  Transformation  never  takes  place,  but  only  replacement 
and  destruction.  In  this  way  the  myeloid  proliferation  in  the 
spleen  first  induces  a  diminution  in  size  of  the  Malpighian 
bodies,  and  then  causes  them  to  disappear  altogether ;  while  in 
lymphatic  proliferation  in  the  bone  marrow  a  lymphatic  tissue 
springs  up  around  the  vessels  and  embraces  them  closely, 
isolating  the  areas  of  normal  medullary  tissue  and  finally 
destroying  them. 

In  delicately  stained  sections  it  can  be  seen  that,  under 
normal  conditions,  lymphocytes  are  only  to  be  found  in  scanty 
numbers  in  the  sheaths  of  the  vessels  and  never  in  the 
parencliyma.  This  is  especially  well  shown  in  specimens 
stained  by  Schridde- Altmann's  method,  which  characterises 
every  lymphocyte  most  definitely. 

The  cells  derived  from  the  two  tissues  show  an  absolutely 
different     biological     activity.     Only     those    derived    from    the 


THE   WTIITE   HLOOl)  CORPUSCLES     140 

bone  maiTow  show  real  (■li(!iiK)La,xiH.  An  increaHe  in  Uie 
numbers  of  lynipliocytes  in  an  exudation  must  depend  on  a 
local  condition,  since  a  large  number  of  these  cells  are  not 
present  in  the  ])lood.  The  cells  of  these  two  tissues  Ijehave 
quite  differently  in  disease  conditions,  so  that  absolutely  striking 
differences  may  be  noted  in  the  blood  appearances  (cf.  the  blood 
curves  of  enteric  fever,  pneumonia,  variola,  etc.). 

The  myeloid  cells  contain  oxydising  and  autolytic  peptic 
ferments  (the  former  is  evidenced  by  the  guaiacol  reaction), 
but  these  are  never  found  in  collections  of  lymphocytes  or  in 
organs  possessing  an  exclusively  lymphatic  nature,  such  as  normal 
lymphatic  gland. 

The  structure  of  the  two  forms  of  tissue  is  absolutely  different. 
In  bone  marrow  a  loose  tissue  with  irregular  intermixture  of 
various  kinds  of  cells  exists,  while  in  the  lymphatic  system  a 
regularly  arranged  structure  is  seen,  in  which  follicles  and 
germinatino;  centres  are  situated. 

These  are  the  most  important  arguments  which  impel  the 
hsematologist  to  accept  the  dualistic  doctrine. 

There  still  remains  one  question  to  be  answered,  namely, 
how  is  it  possible  for  the  so-called  metaplasia  to  occur  under 
certain  circumstances ;  e.g.,  when  myeloid  formation  makes  its 
reappearance  in  the  lymphatic  glands  and  in  the  spleen  ? 
Some  authors  believe  that  this  is  due  to  a  deposition  of  cells 
from  the  blood  channels  (Ehrlich,  K.  Ziegler).  It  seems, 
however,  that  there  is  reason  to  believe  that  it  is  due  to  local 
reactions,  because  the  new  tissue  arises  around  the  vessels, 
while  in  a  number  of  observations  no  increase  of  myelocytes 
has  been  found  in  the  blood. 

We  are  thus  faced  with  one  of  the  most  difficult  problems 
at  the  present  time.  Can  new  formations  arise  out  of  inditfereut 
adventitia  cells  or  out  of  the  "  cells  of  the  vascular  wall " 
(Schridde)  ? 

The  following  views  appear  to  be  calculated  to  throw  the 
greatest  amount  of  light  on  the  subject  at  present,  and  are 
those  which  are  most  frequently  brought  forward  in  discussion. 


150  ANJEMIA 

1.  According  to  Marchand,  those  cells  which  are  associated 
with  the  tunica  adventitia  of  the  vessels  are  capable  of  partici- 
pating in  a  myeloid  transformation.  The  author  supports  this 
view  warmly.  It  is  quite  easy  to  demonstrate  histologically  the 
adventitial  position  of  myeloid  metaplasia,  not  only  in  the 
embryo  but  also  for  the  conditions  obtaining  in  the  adult. 
These  myelocyte  depots  are  often  seen  in  the  neighbourhood  of 
even  large  vessels.  It  can  be  assumed  that  the  cells  implicated 
are  indifferent  cells  which  have  retained  their  embryonal 
character,  according  to  general  biological  laws  (cf.  Eugen  Schultz), 
and  not  cells  which  have  already  passed  through  a  stage  of 
differentiation  and  specialisation. 

One  of  the  most  difficult  questions  to  decide  is  whether 
these  indifferent  cells  may  be  transformed  into  myeloid  or 
lymphatic  tissue,  according  to  the  type  of  stimulus,  or  whether 
there  are  two  different  kinds  of  indifferent  cells  in  the  adven- 
titial coat,  the  one  of  which  is  destined  to  become  lymphatic 
and  the  other  myeloid.  There  can  be  no  doubt  as  to  the 
formation  of  lymphatic  adventitial  depots.  Extensive  examples 
of  this  are  seen  in  caseous  pneumonia,  without  a  single 
lymphocyte  or  any  considerable  number  of  plasma  cells  being 
present  in  the  blood. 

The  author,  working  with  H.  Fischer,  has  recently  been 
able  to  show  that  during  the  developmental  period  erythro- 
poiesis  and  myelopoiesis  occur  independent  of  the  Tunica  adventitia 
in  yoTing  embryonal  connective  tissue,  far  away  from  any  vessel. 
It  therefore  seems  probable  that  connective  tissue  cells  which 
have  retained  their  embryonal  characters  may  develop  into 
myelocytes  as  well  as  adventitial  cells. 

2.  On  the  other  hand,  Schridde  has  enunciated  the  view, 
that  in  the  earliest  embryonal  period  the  "  cells  of  the  vessel 
walls "  give  rise  to  the  new  formation.  He  speaks  of  this  as 
heteroplasia.  In  post-foetal  myeloid  metaplasia  he  suggested 
that  similar  cells,  which  had  retained  their  embryonal  characters, 
serve  this  purpose.  He  does  not  exclude  the  possibility  of  an 
adventitial  genesis,  in  the  sense  in  which  Marchand  and  Naegeli 


THE  WIIITK   lU.OOl)  COKIMJSCLES     151 

use  the  term ;  lie  is,  however,  iiielined  lo  regard  thf;  coIIh  as 
being  cells  detached  from  the  vascular  w.'ill,  and  dcjiosiled  in 
the  adventitia. 

The  tlieoriea  in  vogue  at  present  depend  on  the  assumption  of 
the  presence  of  cells  w^hich  have  retained  embryonal  characters 
and  possibilities  of  development.  This  assumption  is  justified  in 
the  light  of  our  present-day  knowledge,  and  is  supported  by  the 
studies  of  other  organs  {e.g.  oesophagus — Schridde). 

There  is,  however,  one  other  possibility.  Certain  conditions 
are  becoming  known,  in  which  dilTerentiated  cells  lose  their 
differentiation  and  return  to  their  embryonal  types.  These  cells 
can  become  differentiated  again  from  their  simple  condition  in  a 
new  direction.  The  reader  is  referred  to  the  highly  important 
details  given  in  Eugen  Schultz's  work  on  reversible  develop- 
mental processes,  in  which  a  number  of  convincing  facts  with 
regard  to  the  animal  and  vegetable  kingdom  are  recorded.  This- 
"  undifferentiation  "  or  "  dedifferentiation  "  (Schultz)  has  played 
a  considerable  part  in  hsematological  literature  during  recent- 
times  (see  Naegeli's  text-book).  It  has,  however,  not  yet  been 
possible  to  produce  actual  proof  of  the  occurrence  of  this 
process. 

Schridde  has  assumed  recently  that,  apart  from  the  theory  of 
the  preservation  of  embryonal  cells  of  the  vessel  wall,  endothelial 
cells  may  become  undifferentiated  (indirect  metaplasia),  and  thus 
produce  myeloid  tissue.  This  subject  opens  out  great  possi- 
bilities for  future  research. 


v.— LEUCOCYTOSIS 

The  problem  of  leucocytosis  has  been  subjected  to  as  much 
discussion  as  any  question  of  modern  medicine.  An  exhaustive 
recital  of  the  work  devoted  to  it,  of  its  methods,  and  of  the 
results  of  this  work  would  fill  a  whole  volume,  and  would 
be  out  of  place  in  a  treatise  on  blood  diseases.  It  is  therefore 
only  possible  to  describe  the  most  salient  points  in  connection 
with  this  subject  in  general  terms.     Only  the  purely  hiemato- 


152  ANEMIA 

logical     aspects     of     the     question     will     be     dealt     with     in 
detail. 

Virchowgave  the  name  leucocytosis  to  a  temporary  increase 
in  the  number  of  leucocytes  in  blood,  and  taught  that  this 
occurred  in  a  very  large  number  of  physiological  and  pathological 
conditions.  During  the  period  following  the  introduction  of  the 
term  special  attention  was  paid  to  the  occurrence  of  leucocytosis 
in  infective  diseases,  and  the  researches  of  the  last  fifteen  years 
dealing  with  this  subject  have  brought  to  light  some  very  im- 
portant information  with  regard  to  the  biological  significance  of 
this  phenomenon.  The  name  of  Metchnikoff  must  be  mentioned 
in  the  first  place  with  regard  to  this  matter.  This  investigator 
was  able  to  revolutionise  our  ideas  by  means  of  his  phagocyte 
theory.  Even  if  this  theory  has  not  been  able  to  withstand 
criticism  in  many  salient  points,  it  has  certainly  stimulated 
work  on  this  subject,  and  has  been  fruitful  in  advancing  our 
knowledge  of  it. 

In  order  to  sketch  Metchnikoff's  doctrine  briefly,  it  is 
necessary  to  transcribe  the  very  suggestive  word,  phagocyte — 
scavengers.  By  this  term  is  meant  that  the  leucocytes  protect 
the  organism  against  harmful  micro-organisms  by  catching  them 
up  in  their  pseudopods,  by  investing  them  and  thus  robbing 
them  of  the  possibility  of  exerting  their  deleterious  action 
externally.  The  termination  of  an  infective  process  would 
therefore  depend  alone  on  whether  leucocytes  possessing  this 
function  are  present  in  the  blood  in  sufficient  numbers  to  overcome 
the  invasion  of  the  germs. 

In  spite  of  its  very  plausible  nature,  Metchnikoff's  doctrine 
has  been  markedly  limited  by  further  investigations.  Denys, 
Buclmer,  Martin  Hahn,  Goldscheider  and  Jacob,  Lowy  and 
Eichter,  and  many  others  have  proved  in  numerous  publications 
that  the  most  powerful  weapons  of  the  leucocytes  are  not  the 
mechanical  pseudopods,  but  that  their  chemical  products 
(alexins  of  Buchner)  yield  the  strongest  protection  to  the 
organism.  The  leucocytes  are  able,  by  means  of  the  bactericidal 
or  antitoxic  substances  which  they  give  off,  to  paralyse  the  toxins 


Tim  WHITE  15L()()D  COHIMJSCLKS     153 

produced  by  the  bacteria,  and  in  this  way  they  render  the 
microbes  harmless  by  deprivii)<r  tlicm  of  thtsir  weapons  of  attack, 
even  if  they  cannot  destroy  them.^ 

The  explanation  of  the  fact  l\uil  in  biictci'ial  diseases 
leucocytes  are  present  iu  the  blood  almost  always  in  increased 
numbers,  is  based  on  the  principle  which  was  discovered  by 
Pfeffer  of  chemotaxis.  This  is  equally  applicable  whether  the 
chemical  or  the  phagocytic  doctrine  of  leucocytosis  be  accepted. 
According  to  this  principle,  bacteria  or  their  products  are  able 
to  attract  the  cells  stored  up  in  the  blood-forming  organs  by 
means  of  chemical  stimuli  (positive  chemotaxis). 

This,  however,  by  no  means  offers  a  satisfactory  l)iological 
explanation  for  leucocytosis.  It  could  be  shown  that  conditions 
exist,  like  croupous  pneumonia  without  leucocytosis,  in  which, 
in  spite  of  the  presence  of  chemotactically  active  substances,  no 
increase  of  white  blood  corpuscles  appears  in  the  peripheral 
blood. 

Bauer  was  able  to  present  a  particularly  instructive  example 
of  this.  He  showed  that  an  injection  of  the  oil  of  turpentine 
failed  to  produce  leucocytosis  in  a  case  of  enteric  fever  as  it 
does  under  ordinary  conditions.  The  number  of  leucocytes  present 
in  the  blood  in  enteric  fever  is  not  altered.  After  the  patient 
has  lost  his  fever  and  the  medical  practitioner  has  almost 
forgotten  about  the  injection,  the  localisation  abscess  which  he 
had  tried  to  produce  then  appears.  The  explanation  is  quite 
obvious.      Leucocytosis    does    not   merely   depend    on    a   mere 

^  Naegeli  appears  to  have  somewhat  confused  the  issues  by  classifying 
bactericidal  and  antitoxic  properties  together.  With  regard  to  the  latter,  it  must 
be  remembered  that  hitherto  a  comparatively  small  number  of  these  substances 
has  been  found  in  the  serum  of  animals  sufleriug  from  bacterial  diseases.  "With 
regard  to  the  bactericidal  properties,  Naegeli  appears  to  have  overlooked  that  the 
very  name  indicates  a  killing  of  the  bacteria,  and  for  this  reason  the  possible 
protection  afforded  to  the  organism  -would  depend  in  this  case  on  the  removal  of 
the  living  germs  themselves.  "Whether  this  bactiericidal  action  and  the  bacterio- 
lytic action,  Mith  which  it  is  closely  associated,  are  free  from  further  effects  than 
those  of  protection  cannot  be  discussed  in  this  place.  It  must  further  be  pointed 
out,  that  while  the  leucocytes  yield  ferments,  usually  known  as  alexins  and 
complements,  the  action  of  killing  or  dissolving  bacteria  or  of  pai-alysing  their 
products  should  not  be  regarded  as  properties  of  the  leucocytes. — (The  Translator.) 


154  ANJEMIA 

chemical  attraction  of  cells  from  the  blood  and  bone  marrow : 
it  depends  first  and  foremost  on  a  stimulation  to  increase  the 
function  of  the  bone  marrow,  and  only  as  a  secondary  process 
does  the  chemotaxis  come  into  play.  If  the  bone  marrow  is 
incapable  of  responding  to  the  stimulation  by  increased  activity 
no  leucocytosis  takes  place,  in  spite  of  the  fact  that  the 
chemotactic  substances  are  present. 

It  used  to  be  taught-  that  in  those  diseases  which  were 
characterised  by  a  diminution  of  leucocytes  in  the  blood,  i.e.  by 
leucopenia,  there  was  a  negative  chemotaxis,  and  that  the  cells 
are  repulsed  by  chemical  substances  produced  in  these  diseases. 
Leucopenia  is,  as  a  matter  of  fact,  a  much  more  complicated 
biological  process,  and  its  origin  in  a  negative  chemotaxis  is 
extremely  doubtful 

Numerous  phenomena  have  been  elicited  in  connection  with 
the  careful  study  of  leucocytosis  produced  experimentally  by 
bacterial  toxins  and  proteins,  organ  extracts,  poisons,  etc.,  which 
still  need  special  explanation. 

Lowit  was  able  to  show  that  when  these  substances  were 
introduced,  two  separate  stages  could  be  distinguished  in  the 
behaviour  of  the  leucocytes.  First,  there  was  a  stage  in  which 
the  leucocytes  were  diminished  in  number  (leucopenia — Lowit). 
In  this  stage  only  the  polynuclear  cells  were  diminished  in 
number,  while  the  lymphocytes  were  present  in  their  normal 
proportions.  Following  this  came  the  phase  of  increase  of  the 
white  corpuscles,  which  also  only  affected  the  polynuclear  cells : 
polynuclear  leucocytosis.  This  behaviour  seemed  to  indicate 
that  the  first  period  signalised  a  destruction  of  white  cells  by 
the  agency  of  a  foreign  substance,  and  that  the  dissolved  products 
of  the  leucocytes  chemotactically  produced  a  migration  of  fresh 
leucocytes.  This  view,  however,  soon  met  with  various  objections. 
Goldscheider  and  Jacob  demonstrated,  by  means  of  painstaking 
experiments,  that  the  temporary  leucopenia  of  the  blood  was 
not  a  true  one,  but  was  only  apparent,  and  was  caused  by  an 
alteration  in  the  distribution  of  the  white  blood  corpuscles 
inside  the  vascular  system.     While  the  blood  of  the  peripheral 


THE  \A111TE   HLOOI)  ( OKPLSCLKS     155 

vessels,  from  wliioh  us  a  rule  the  siuujdo.s  are  taken  for  exaniiua- 
tion,  showed  a  (Ihuinutiou  of  leueocytes  —  a  liypoleucocytosis, 
the  blood  of  the  capillaries  of  the  internal  organs,  and  especially 
of  the  lungs,  showed  a  marked  increase  in  the  nundjer  of  leuco- 
cytes— a  hyperleucocytosis. 

There  is  a  number  of  ini])ortant  facts  which  speak  definitely 
against  the  essential  significance  which  Lowit  has  ascribed  to 
leucopenia.  There  is  no  reason  to  believe  that  tlie  various 
substances  which  were  shown  to  exercise  a  distinct  chemotactic 
action  on  the  leucocytes  in  the  original  test  tube  experiments 
should  under  altered  conditions  require  the  assistance  of  the  dis- 
integration products  of  the  white  blood  corpuscles  to  perform  this 
task.  But  apart  from  this  it  may  be  said  that  clinical  experience 
in  general  speaks  against  Liiwit's  theory.  In  infectious  diseases 
a  hyperleucocytosis  is  noted  very  frequently,  while  even  a 
temporary  leucopenic  stage  is  extremely  rare. 

The  fact  that  this  does  not  correspond  with  the  observations 
made  by  Lbwit  in  his  experiments  is  readily  explained  when  it 
is  considered  that  the  condition  of  experiment  differed  materially 
from  the  processes  of  natural  disease.  In  the  former  case  the 
experiment  animal  is  suddenly  overwhelmed  by  an  intravenous 
injection  of  a  noxious  substance,  which  necessarily  is  followed 
by  a  violent  acute  reaction  of  the  vascular  and  blood  systems. 
In  a  natural  infection  the  quantity  of  poison  increases  gradually, 
and  only  exerts  its  toxic  influence  little  by  little.  For  this 
reason  it  is  probable  that  hypoleucocytosis  is  much  rarer  in 
infective  processes  with  a  normal  course  than  under  the  violent 
conditions  of  an  experiment. 

A  vast  amount  of  literature  has  accumulated  which  deals 
with  the  clinical  significance  of  leucocytosis,  especially  wiih 
regard  to  the  infectious  diseases  and  their  various  stages.  To 
select  one  of  the  most  carefully  studied  examples,  namely,  that 
of  pneumonia,  it  can  be  said  that  the  occurrence  of  leucocytosis 
as  a  constant  phenomenon  during  the  typical  conrse  of  this 
disease  is  undisputed.  It  lasts  practically  right  up  to  the 
onset  of  the  crisis,  and  from   this  time   ojiward   the   number   of 


156  ANiBMIA 

leucocytes  diminishes  to  below  the  normal  level.  The  observa- 
tions that  leucocytosis  may  be  absent  in  the  specially  severe 
or  fatal  cases  are  of  great  importance  (Kikodse,  Sadler,  v.  Jakscli, 
Tschistowitsch,  Tiirk,  and  others). 

The  same  observation  was  made  in  other  diseases,  that 
hyperleucocytosis  is  usually  absent  in  those  cases  which  run  a 
particularly  severe  course  or  which  are  in  the  least  atypical.  It 
has  further  been  shown  by  several  observers  (Lowy  and  Eichter, 
M.  Hahn,  Jacob)  that  an  artificial  hyperleucocytosis  influences 
the  course  of  an  infective  process  favourably,  at  all  events  in 
experiment  animals. 

Practical  results  in  the  treatment  of  disease  on  this  basis 
have  not  been  achieved,  because  only  the  specific  mode  of  pro- 
ducing the  leucocytes  which  is  peculiar  to  each  disease  exercises 
a  decided  influence  on  the  course  of  illness.  A  mere  increase 
in  the  number  of  cells  fails  to  effect  this  action. 

The  fact  that  the  amount  of  toxin  is  a  very  important  factor 
in  determining  the  degree  of  leucocytosis  is  a  very  interesting 
one.  As  has  been  demonstrated  by  a  number  of  experiments 
(Tschistowitsch,  Williamson,  Jacob),  a  small  dose  of  toxin  leads 
to  a  slight  leucocytosis,  higher  doses  produce  well  -  marked 
leucocytosis,  while  very  large  quantities  of  toxin  induce  an 
insufficiency  of  the  bone  marrow,  and  consequently  prevent  a 
reactive  increase  of  the  cells  in  the  blood.  The  last-named 
case  usually  gives  rise  directly  to  leucopenia.  A  number  of 
analogies  to  these  experimental  observations  may  be  found  in 
the  special  pathology  of  the  infectious  diseases.  The  most 
convincing  of  these  is  included  in  the  publications  of  Sonnenburg 
and  his  pupils  Federmann  and  Kothe ;  these  authors  report  that 
some  forms  of  perityphlitis  begin  with  a  very  high  degree  of 
leucocytosis,  which  may  last  only  for  a  few  hours,  and  then  the 
numbers  may  fall  rapidly  to  normal  and  even  subnormal  levels. 
Observations  of  this  kind  are  calculated  to  demonstrate  in  a 
most  striking  manner  that  leucocytosis  is  not  a  purely  chemo- 
tactic  process,  which  is  merely  dependent  on  the  movements 
of  leucocytes,  but  that  it  must  be  a  highly  complicated  biological 


THE   WIiriK   r>L()()I)  COllJMJSCLKS      157 

phenomenon,  the  form  of  wliicli  i.s  largely  detoi'minorl  ])y  Llio  power 
of  reacting  on  the  part  oi  the  bone  marrow.  The  definition  of 
the  word  chemotaxia  might,  it  is  true,  he  extended  to  include 
a  distant  action  of  chemical  .suhstiMiccH  in  gcncial  on  the  blood 
and  blood-producing  organs,  instead  of  simply  applying  to  the 
attraction  and  local  movement  of  the  leucocytes. 

On  the  application  of  a  suitable  dose  of  the  chemical  substance 
a  stimulation  of  the  cells  present  in  the  bone  marrow  would 
take  place,  which  would  be  evidenced  Ijy  a  proliferation  of  the 
marrow  cells  and  as  a  rule  by  an  increased  output  into  the 
blood  of  these  cells.  When  other  doses  are  applied  a  hyper- 
sensibility  of  the  medullary  elements  would  be  produced,  under 
the  influence  of  which  the  immature  mononuclear  forms  would 
leave  the  marrow,  and  in  this  way  all  pronounced  increase  of 
cells  in  the  central  organs  would  cease.  Eegarded  in  the  more 
extended  light,  the  chemotaxis  as  defined  formerly,  i.e.  the 
locomotion  of  the  leucocytes,  would  then  only  form  a  part  of 
the  whole  process. 

Leucocytes  may  be  divided  from  this  point  of  view  into  : 
(1)  Simple  leucocytes,  usually  endowed  with  distant  action 
(formerly  spoken  of  as  active),  and  (2)  leucocytes  without  the 
capability  of  distant  action  (formerly  termed  passive).  The 
lymphocytes  would  belong  to  the  latter  group. 

Having  regard  to  the  fact,  mentioned  above,  that  the  same 
substance  may  produce  leucocytosis  or  not  according  to  the 
dose,  it  can  scarcely  be  supposed  that  a  diminution  in  the 
number  of  leucocytes — leucopenia — is  a  process  which  has  no 
connection  with  leucocytosis.  Both  conditions  can  very  well  be  pro- 
duced by  the  same  cause,  and  must  therefore  be  regarded  as  differ- 
ing only  in  degree,  in  correspondence  with  the  dose  of  toxin. 

The  close  relationship  may  further  be  shown  to  exist  in  the 
fact  that  a  diminution  or  even  total  disappearance  of  one  kind 
of  leucocyte  frequently  occurs  even  when  the  total  number  is 
greatly  increased.  In  other  words,  there  may  be  a  leucocytosis, 
say,  of  the  neutrophile  cells  simultaneously  with  a  leucopenia 
of  the  eosinophiles ;  this  occurs  quite  frequently.     Leucocytosis 


158  ANEMIA 

and  leucopenia  are  thus  the  morphological  expression  of  bio- 
logical processes  in  the  function  of  the  leucocyte-forming  organs. 
Marked  diminution  in  number  of  the  white  blood  corpuscles 
is  very  characteristic  of  certain  diseases,  especially  enteric 
fever.  The  neutrophile  elements  are  most  frequently  affected, 
especially  when  the  disease  has  reached  its  acme  and  in  the 
final  stages.  The  conclusion  to  be  derived  from  the  foregoing  is 
that  the  toxin  of  typhoid  fever  specially  damages  the  function 
of  bone  marrow.  This  assumption  has  been  confirmed  by 
animal  experiment  (JSTaegeli,  Studor),  and  has  received  support 
from  the  fact  that  a  neutrophile  leucocytosis  does  not  occur  in 
severe  cases,  even  when  certain  factors  are  present  which  tend 
to  produce  leucocytosis,  such  as  pneumonia,  abscesses,  turpentine 
injections,  etc. 

Considerable  degrees  of  leucopenia  are  met  with  in  severe 
cases  of  enteric  fever,  at  the  onset  of  morbilli,  frequently  in 
•cirrhosis  of  the  liver,  as  well  as  in  severe  forms  of  anaemia  of 
various  origin,  and  especially  as  a  regular  find  in  Biermer's 
pernicious  anaemia,  under  which  condition  the  cause  of  the 
■disease  does  not  play  any  part.  The  characteristic  changes  in 
these  cases  include  those  cells  which  are  derived  from  the 
bone  marrow, — that  is,  neutrophile  cells,  transition  forms,  and 
eosinophile  cells,  which  are  much  diminished  in  absolute  numbers, 
often  as  low  as  one-fourth  to  one-sixth  of  the  normal  number, 
while  the  lymphocytes  appear  in  abnormally  high  percentages, 
although  their  absolute  values  correspond  approximately  to  the 
normal. 

A  steady,  slow  increase  in  the  number  of  the  leucocytes  is 
seen  regularly  during  remissions  in  this  disease. 

The  explanation  for  this  peculiar  character  of  the  blood  in 
pernicious  antemia  is  obvious.  The  leucopoiesis,  like  the  ery- 
thropoiesis,  is  markedly  inhibited  and  insufficient. 

Excluding  leucopenia,  which  would  result  from  a  destruction 
of  a  part  of  the  white  blood  corpuscles  (Lowit)  on  the  ground 
that  it  is  non-proven,  the  following  causes  of  the  phenomenon 
•of  leucocytosis  may  be  accepted  : — 


rilE  WHITE  J5LOOD  COIUMJSC  LKS     159 

1.  Abnorinal  disirihution. — This  in  nivn.  .'iiid  tran.sitoiy.  The 
leucocytes  colloot  in  the  capillaries  of  tin;  inteiDul  organs  after 
intravenous  injcsctioiis. 

2.  Ahnurvifdljj  hhihII  fiupj)ly  of  leucocytes. — 

{<()     Duo    to    toxic,    functional    inhibition    of    the 
foiniation  of  leucocytes,  as  in  infectious  diseases, 
])()is(»iiing,  and  anaemia. 
{]))  Duo  to  anatomical  destruction  of  the  If-ucopoietic 
organs,  as   in   extensive   tuberculosis   or  .car- 
cinosis   of    tlie   lymphatic   system,   in    which 
case   the  lymphocyte  values  are    ]»ermanently 
and  markedly  lowered. 
It  lias  never  been  proved  that  negative  chemotaxis  affects  the 
cells  of  the  blood. 

.The  morphological  character  of  leucocytosis  is  Ijy  no  means 
uniform,  and  it  is  therefore  necessary  to  divide  the  increase  of 
the  leucocytes  into  various  groups,  according  to  the  kind  of  cell 
which  participates  in  the  increase. 

Ehrlich  formerly  recognised  an  active  leucocytosis  in  which 
the  cells  obeyed  a  chemotactic  law  and  migrated  spontaneously 
into  the  blood,  and  a  passive  form  in  which  the  cells  were 
washed  mechanically  into  the  circulation.  In  accordance  with 
his  view,  that  the  lymphocytes  are  not  endowed  with  any 
active  movement,  Ehrlich  included  all  forms  of  lymphocytosis, 
including  lymphatic  leukeemia,  among  the  passive  leucocytoses. 

The  extension,  of  the  conception  of  chemotaxis  rendered  it 
impossible  to  adhere  to  this  division,  especially  since  the  chief 
importance  is  invested  in  the  influence  exercised  on  the  formation 
of  cells  in  the  organs,  or  in  other  words  in  organ  function. 

"Whenever  any  kind  of  cell  is  present  in  the  blood  in 
increased  numbers  a  more  intense  activity  of  the  organ  in 
which  these  cells  are  formed  undoubtedly  takes  place. 

Leucocytosis  may  be  divided  according  to  the  class  of  cell 
which  is  increased.  An  increase  of  more  than  one  kind  of 
leucocyte  may  not  infrequently  be  met  with  in  one  disease. 


160  ANEMIA 

A. — Polymorpho-nuclear  NeutropMle  Leucocytosis 

By  far  the  most  common  form  of  leucocytosis  is  that  in  which 
the  polynuclear  neutrophils  leucocytes  are  increased  in  numbers. 
A  larffe  number  of  the  most  different  conditions  and  influences 

O 

lead  to  its  occurrence. 

Virchow,  the  discoverer  of  leucocytosis,  was  of  opinion  that 
leucocytosis  depended  on  an  increased  stimulation  of  the  lym- 
phatic glands.  He  taught  that  the  stimulation  of  the  lymphatic 
glands  consists  in  "  the  taking  on  of  an  increased  production  of 
cells  and  in  the  enlargement  of  the  follicles,  in  which,  after  a  time, 
many  more  cells  are  contained  than  before."  The  swelling  of  the 
lymphatic  glands  was  supposed  to  induce  an  increase  in  the 
number  of  lymph  corpuscles,  and  from  this  followed  an  increase 
in  the  number  of  white  blood  corpuscles  in  the  blood. 

Ehrlich's  researches  necessitated  the  relinquishing  of  this 
view,  since  they  showed  that  the  migration  of  the  polynuclear 
neutrophile  cells  was  to  a  large  extent  responsible  for  the 
leucocytosis.  Exact  cell  counts  were  first  carried  out  by  Einhorn 
under  Ehrlich's  direction,  and  later  on  the  results  obtained  were 
generally  confirmed.  In  correspondence  to  the  increase  which 
was  limited  to  the  neutrophile  corpuscles,  the  percentage  of  the 
lymphocytes  was  always  found  to  be  diminished,  at  times  to  such 
an  extent  that  these  cells  only  represented  2  per  cent,  or  less  of 
the  total  number  of  white  cells.  It  must,  however,  be  remembered 
that  the  percentage  of  the  lymph  cells  may  be  markedly 
diminished  without  their  absolute  number  being  altered.  But  it 
has  frequently  been  found  that,  associated  with  the  polynuclear 
leucocytosis,  a  decrease  in  the  absolute  number  of  lymphocytes 
takes  place. 

The  transition  forms  often  show  considerable  increase  in 
neutrophile  leucocytosis,  and  single  neutrophile  myelocytes  may 
be  found  *  among  these  cells.  This  increase  may  even  reach  a 
moderately  high  percentage.  Apart  from  the  appearance  of 
myelocytes  and  of  numerous  immature  leucocytes,  the  fact  that  a 
few  nucleated  red  blood  corpuscles  may  be  found  in  the  peripheral 


THE  WHITE  BLOOD  CORPUSCLES     lOi 

blood  in  the  absence  of  anaemia,  speaks  strongly  in  favoui-  f)f  the 
view  that  the  bon(3  marrow  is  working  at  very  iiigh  pressure. 

In  the  ordinary  forms  of  polynuclear  neutrophile  leucocytosis 
the  eosinophile  cells  are  usually  absolutely  diminished  in  number, 
as  Ehrlich  pointed  out  in  his  first  publication  on  this  subject. 
Tlie  diminution  is  frequently  a  considerable  one,  and  at  times 
these  cells  may  be  absent  altogether. 

In  a  few  pathological  conditions  there  may,  however,  be  an 
increase  of  eosinophile  cells  in  association  with  a  polynuclear 
neutrophile  leucocytosis.  This  will  be  dealt  with  under  a  separate 
heading. 

Polynuclear  neutrophile  leucocytosis  —  leucocytosis  par 
excellence — may  be  divided  into  several  groups  according  to  its 
clinical  occurrence.     The  following  forms  are  recognised  : — 

(i)  PHYSIOLOGICAL  LEUCOCYTOSIS 

The  leucocytosis  of  digestion  must  be  included  in  this  group. 
This  is  said  to  occur  after  the  ingestion  of  albuminous  food. 
Japha,  however,  is  of  opinion  that  this  is  merely  a  physiological 
diurnal  variation.  While  the  older  authors  found  that  the 
lymphocytes  were  increased,  more  recently  an  increase  of  the 
neutrophiles  has  been  said  to  occur. 

According  to  the  more  recent  investigations,  the  leucocytosis  of 
pregnancy  only  affects  primiparce  regularly,  and  even  in  them  is 
but  slight.     It  affects  the  neutrophiles  chiefly. 

The  leucocytosis  of  new-born  infants  is  only  marked  in  the 
first  four  days  of  life  and  is  of  a  neutrophile  character. 

Increased  numbers  of  leucocytes  can  also  be  found  in  the 
peripheral  blood  after  bodily  over-exertion  and  thermic  stimuli. 
It  is,  however,  possible  that  vasomotor  changes  may  be  responsible 
for  this,  at  all  events  in  part. 

(ii)    ATHOLOGICAL  LEUCOCYTOSIS 

1.  The  increase  in  the  number  of  the  polynuclear  cells  which 
occurs  in  infectious  processes  has  been  called  inflammatory,  in 
accordance  with  the  principle:  a  potior i  fit  dcnominatio.     They 
II 


162  ANEMIA 

are  nevertheless  inflammatory  toxic  processes,  since  the  toxins  of 
the  infective  microbes  determine  the  character  of  the  leucocytosis. 
This  has  been  proved  beyond  all  doubt  by  innumerable  experi- 
mental researches.  It  is  particularly  important  to  note  that  the 
majority  of  febrile  conditions,  c.^r.  pneumonia,  erysipelas,  diphtheria, 
septic  conditions  of  various  origin,  acute  articular  rheumatism,  etc., 
are  accompanied  by  a  definite  more  or  less  marked  leucocytosis. 
Uncomplicated  enteric  fever  and  morbilli  alone  occupy  an 
exceptional  position  in  this  connection.  The  absolute  number  of 
white  blood  corpuscles  in  these  diseases  is  decreased  often  at  the 
cost  of  the  polynuclear  neutrophile  cells.  The  reader  is  referred 
to  the  various  text-books  on  hematology,  and  to  the  publications 
of  Tiirk,  Stienon,  Schindler,  Eeckzeh,  Zappert,  and  others  for  the 
details  with  regard  to  this  behaviour,  and  also  for  the  course 
and  termination  of  leucocytosis  associated  with  the  infectious 
diseases. 

The  chronic  infective  processes,  and  above  all  tuberculosis, 
produce  extremely  slight  changes  in  the  blood,  so  that  no 
constant  variations  from  the  normal  can  be  ascertained. 

As  a  rule  the  acute  infectious  diseases  begin  with  a  consider- 
able neutrophile  leucocytosis.  This  may,  as  is  the  case  in  measles, 
fall  during  the  incubation  stage,  or,  as  is  the  case  in  typhoid 
fever,  may  last  for  an  extremely  short  time ;  as  a  rule  it  lasts 
for  a  considerable  time.  During  this  stage  the  lymphocytes  are 
diminished  and  the  eosinophiles  are  either  greatly  reduced  in 
number  or  disappear  from  the  blood  altogether.  As  the  infection 
passes  off  the  lymphocyte  curve  rises  again,  as  does  that  of  the 
eosinophiles,  and  during  convalescence  the  curves  may  reach  a 
level  higher  than  normal,  which  is  spoken  of  as  post-infective 
lymphocytosis  and  eosinophilia.  This  is  in  accordance  with  a 
general  biological  law  which  states  that  a  diminished  activity  of  a 
tissue  is  followed  by  an  activity  after  recovery  which  exceeds  the 
normal. 

2.  Toxic  leucocytosis  is  met  with  especially  in  poisoning  with 
the  so-called  blood  poisons.  The  majority  of  blood  poisons,  such 
as     potassium    chlorate,    the    derivatives     of     phenyl-hydrazin, 


THE  WHITE  BLOOD  CORPUSCLES     1 03 

pyrodin,  phenacetin,  etc.,  in  general  appear  to  x^roduce  a  consider- 
able increase  of  leucocytes  in  human  beings,  as  well  as  to  destroy 
the  red  blood  cells.  This  has  been  confirmed  experimentally. 
It  must  further  be  mentioned  that  marked  leucocytosis  may  be 
produced  by  the  injection  of  tissue  extracts  containing  nuclein 
and  of  nuclein  alone. 

3.  The  leucocytosis  of  ansemic  conditions  and  ha-moirhages 
is  especially  well  known  as  post-h[emorrhagic  leucocytosis.  It 
indicates  a  strong  bone  marrow  reaction,  which  affects  inter  alia 
the  white  blood  corpuscles. 

4.  The  leucocytosis  of  malignant  tumours  is  not  constant,  but 
may  be  very  marked.  The  cause  must  be  sought  in  various 
factors,  e.g.  in  the  absorption  of  toxic  substances  in  the  decom- 
position of  fouling  discharges. 

A  particularly  great  increase  is  met  with  in  metastases 
occurring  in  the  bone  marrow.  In  these  cases  nucleated  red 
blood  corpuscles  and  numerous  myelocytes  may  pass  into  the 
blood,  so  that  the  blood  presents  an  appearance  similar  to  that 
seen  in  leukaemia. 

The  so-called  cachectic  or  agonal  leucocytosis  does  not  depend 
on  cachexia  or  agony  as  such,  as  used  to  be  held.  It  is  frequently 
absent  in  both  conditions.  When  it  is  present  it  is  the  result  of 
the  condition  producing  the  cachexia  or  agony. 

It  is  quite  clear  that  the  conditions  of  the  cells  of  the  blood  in 
the  various  diseases  may  be  of  considerable  clinical  importance. 
It  is  only  possible  to  touch  on  a  few  of  the  more  salient  points  in 
this  place,  and  to  refer  the  reader  to  the  text-books  on  morpho- 
logical liEematology  for  further  details. 

(a)  The  great  importance  in  the  differential  diagnosis  which 
attaches  to  the  leucopenic  blood  condition  in  enteric  fever  as 
contrasted  with  nearly  all  other  infectious  diseases. 

The  early  diagnosis  of  measles  during  the  incubation  period. 

The  recognition  of  trichinosis  and  the  extraordinarily  easy 
differential  diagnosis  between  trichinosis  and  typhoid  fever,  which 
used  to  be  difficult  to  make. 


164  ANEMIA 

The  importance  of  leucocytosis  for  the  recognition  of  suppura- 
tive processes,  and  of  the  tendency  of  these  processes  to  become 
extended. 

(h)  The  prognostic  importance  of  changes  of  this  kind  in  the 
blood,  e.g.  the  absence  of  leucocytosis  in  severe  diseases,  in  which 
a  marked  increase  of  the  neutrophile  cells  would  otherwise  have- 
been  expected  from  the  nature  of  the  process,  would  indicate  an 
insufficiency  of  the  bone  marrow,  and  would  therefore  point  to 
a  very  severe  affection  (examples :  pneumonia,  perityphlitis,, 
peritonitis,  etc.). 

Ehrlich  teaches  that  the  origin  of  polymorpho-nuclear  neutro- 
phile leucocytosis  lies  in  the  bone  marrow.  It  is  not  necessary 
now  to  support  this  view  with  as  many  arguments  as  it  was  ten 
years  ago.  This  does  not  mean  that  there  are  no  persons  left  who 
believe  that  the  origin  of  leucocytosis  should  be  sought  for  in  the 
inflammatory  and  suppurative  foci,  in  the  intestinal  wall,  in  the 
mucous  membrane  of  the  uterus,  and  so  on,  but  views  of  this  kind 
may  be  treated  to-day  as  curiosities.  The  origin  of  the  neutro- 
phile elements  in  the  bone  marrow  is  firmly  established,  because- 
in  no  other  organ  are  the  precursors  of  the  neutrophiles  of  the 
blood — the  myelocytes — to  be  found.  They  are  present  in  these 
organs  in  tissue  formations  in  very  large  numbers.  In  this  situa- 
tion all  forms  of  transposition  of  the  nucleus,  and  all  forms 
intermediate  to  those  of  the  cells  found  in  the  blood,  are  present. 
Mitosis  is  found  in  this  situation,  and  even  if  there  is  no  doubt 
that  in  certain  pathological  conditions  myeloid  formations  appear 
in  other  organs,  the  functional  significance  of  these  extraneous 
formations  is  only  very  subordinate,  save  perhaps  in  leukaemia. 

B. — Polynuclear  Eosinophile  Leucocytosis. 

After  Ehrlich  had  demonstrated  the  constant  increase  of  the- 
eosinophile  cells  in  leukaemia,  a  long  time  passed  before  eosino- 
philia  was  found  in  any  other  form  of  disease,  the  characters  of 
which  differed  essentially  from  leuksemia.  The  first  advance  in 
this  direction  was  made  by  Friedrich   Miiller,  on  whose  advice^ 


THE  WHITE  lU.OOI)  CORPUSCLES     1G5 

■CJollasch  examined  tlio  l)lf)()(I  of  asthmatics  and  found  therein  a 
•distinct  increase  in  the  nuinhor  of  eosinophile  colls.  Following 
this,  H.  F.  Miiller  and  Kiedcr  discovered  that  eosinophilia  exists 
with  great  frequency  in  children  and  in  connection  with  chronic 
splenic  tumours.  Next  followed  the  well-known  work  of  Edm. 
Neusser,  in  which  he  proved  that  a  very  marked  increase  of  the 
oxyphilic  elements  occurs  in  pemphigus  and  almost  simultaneously 
analogous  observations  by  Canon  in  chronic  skin  diseases.  It  is 
only  necessary  to  mention  the  comprehensive  survey  of  this 
subject  published  by  Zappert  and  K.  Meyer  from  among  the 
•enormous  number  of  other  communications. 

By  the  term  eosinophilia  is  meant  an  increase  of  the  cells 
of  the  blood  affecting  the  eosinophile  polyuuclear  cells  alone.  It 
is  quite  impossible  to  confuse  this  form  of  leucocytosis  with 
leukaemia,  because  a  whole  series  of  other  characteristic  signs  is 
necessary  for  the  recognition  of  the  latter.  These  signs  will  be 
dealt  with  in  the  following  chapter.  It  is  not  permissible  to 
regard  the  presence  of  mononuclear  eosinophile  cells  in  the  blood 
as  absolute  proof  of  a  leukaemia,  as  some  authors  have  done,  since 
these  cells  are  found  in  some  cases  of  ordinary  leucocytosis. 

The  increase  in  the  number  of  the  eosinophile  cells  is  in  every 
case  not  only  a  relative,  but  also  an  absolute  one.  The  percentage 
of  these  cells  under  normal  conditions  is  from  2  to  4  per  cent.,  but 
rises  in  eosinophilia  to  10,  20,  30  per  cent,  and  higher. 

Polynuclear  eosinophile  leucocytosis  is  found  in  manifold 
pathological  conditions,  as  well  as  in  healthy  children,  and  for 
the  sake  of  clearness  these  conditions  may  be  divided  into  the 
following  groups. 

1.  Bronchial  Asthma. — In  this  disease  an  increase,  which 
is  frequently  very  considerable,  in  the  number  of  eosinophile 
cells  in  the  blood  was  first  discovered  by  Gollasch,  and  this 
was  confirmed  later  by  a  large  number  of  other  observers.  The 
percentage  may  rise  to  10  and  20  per  cent,  or  higher.  In  hay 
asthma  and  hay  fever  absolutely  similar  conditions  are  met  with. 
(For  the  special  clinical  course  of  eosinophilia  in  asthma,  see 
below.) 


166  ANEMIA 

2.  Pemphigus. — Neusser  was  the  first  to  find  an  extra- 
ordinarily marked  almost  specific  eosinophilia  in  some  cases  of 
pemphigus.  This  interesting  observation  has  been  confirmed  by 
a  number  of  workers,  among  whom  Zappert  should  be  mentioned. 
The  latter  found  in  one  case  as  many  as  4800  oxyphile  cells  in  a 
c.mm,  of  blood. 

3.  Acute  and  Chronic  Skin  Diseases.— Canon  was  the 
first  to  notice  that  in  a  large  number  of  skin  diseases,  especially 
in  prurigo  and  psoriasis,  the  eosinophile  cells  may  be  increased 
up  to  17  per  cent.  Canon  pointed  out  one  remarkable  fact,  that 
it  is  not  so  much  the  kind  of  disease  or  its  local  intensity  as  the 
extent  of  the  process  which  determines  the  degree  of  the  increase 
of  the  eosinophile  elements.  In  one  case  of  acute  very  extensive 
urticaria  A.  Lazarus  found  the  eosinophiles  representing  60  per 
cent,  of  all  the  leucocytes ;  within  a  few  days  this  enormous 
number  of  eosinophile  cells  diminished  to  the  normal  level. 

4.  Helminthiasis. — The  first  observations  with  regard  to 
the  occurrence  of  eosinophilia  in  helminthiasis  emanated  from 
H.  F.  Mliller  and  Kieder,  who  demonstrated  fairly  high  values 
(8*2  and  9*7  per  cent.)  in  two  men  suffering  from  ankylostomum 
duodenale.  Shortly  afterwards  Zappert  reported  that  he  had 
found  a  considerable  increase  of  these  cells  in  the  blood  of  two 
further  cases  of  the  same  disease ;  the  value  reached  17  per  cent. 
He  also  found  Charcot's  crystals  in  the  faeces.  In  a  third  case  of 
ankylostomum,  however,  Zappert  failed  to  find  the  eosinophiles 
of  the  blood  increased,  or  any  crystals  in  the  fseces.  Seige  also 
found  similar  conditions. 

Leichtenstern,  whose  work  on  parasitology  is  well  known,  has 
published  an  extensive  essay  on  this  important  subject.  Under 
his  direction  Biicklers  discovered  the  interesting  fact  that 
ankylostomum  does  not  take  an  exceptional  position  among  the 
diseases  produced  by  worms  with  regard  to  the  production  of 
eosinophilia.  He  found  that  all  the  forms  of  worms  observed  in 
the  Cologne  Hospital,  from  the  thread-worm  which  is  generally 
regarded  as  harmless  to  the  pernicious  strongylus,  produced  an 
increase  of   the   eosinophile   cells   in  the  blood,  which  at  times 


THE   WHITK  KLOOD  COJlPliSCLKS     107 

reached  a  great  height.  BiicklerH  reported  that  he  found  16  per 
cent,  of  eosinophiles  in  oxyuris,  19  per  cent,  in  Ascaris  lura- 
hricoides,  and  Leichtenstern  announced  in  a  later  communication 
that  he  had  come  aci'os.s  a  ca.se  of  ankylostomiasis  with  72  per 
cent,  of  eosinophiles  and  one  case  of  Tmnia  mediocanelkUa  witli 
34  per  cent. 

It  is  very  remarkable  that  Leichtenstern  was  able  to  find 
large  numbers  of  eosinophile  cells  especially  in  those  cases  in 
which  the  fcieces  contained  quantities  of  Charcot's  crystals.  Since 
eosinophile  cells  and  Charcot's  crystals  have  on  other  occasions 
been  frequently  found  associated  with  one  another  (e.r/.  in 
bronchial  asthma,  nasal  polypi,  in  myelremic  blood  and  bone 
marrow)  it  is  quite  reasonable  to  accept  Leichtenstern's  thesis, 
that  eosinophile  cells  may  be  present  in  the  intestinal  mucosa  in 
ankylostomiasis.     This  has,  however,  not  yet  been  demonstrated. 

The  almost  constant  increase  in  numbers  of  eosinophile  cells 
in  trichinosis  has  proved  to  be  of  great  diagnostic  value.  This- 
fact  was  first  discovered  by  T.  E.  Brown,  working  under  the- 
direction  of  Thayer.  He  found  the  eosinophile  value  as  high  as 
68  per  cent,  and  the  absolute  value  as  high  as  20,400. 

Since  Brown's  communication,  analogous  observations  have 
been  made  by  Schleip  among  others  in  a  large  epidemic,  and  by 
Opie  and  Straubli  in  experimental  trichinosis.  It  has  on  many 
occasions  been  possible  to  clear  up  clinically  obscure  or  doubtful 
cases  by  means  of  haematological  examination. 

5.  The  Post- infective  Form  of  Eosinophilia  (after  the 
termination  of  various  infectious  diseases). — As  has  been  men- 
tioned in  the  chapter  dealing  with  polyuuclear  neutrophile 
leucocytosis,  a  relative  diminution  of  the  number  of  eosinophiles 
or  even  a  total  disappearance  of  these  cells  may  be  seen  at  the 
height  of  the  fever  in  the  infectious  diseases,  with  the  one  ex- 
ception of  scarlatina.  In  the  post-febrile  stages,  however,  the 
highest  values  which  can  still  be  considered  normal  are  often  met 
with,  or  there  may  even  be  a  distinct  eosinophilic  leucocytosis. 
When  this  occurs  it  is  usually  quite  moderate  in  degree. 

Not  infrequently,  however,  very  considerable   increases  may 


168  ANEMIA 

be  noted,  as  in  the  case  of  typhoid  fever,  when  the  numbers  may 
be  as  high  as  from  1200  to  1500;  this  can  be  seen  more  often  if 
the  blood  is  examined  for  a  considerable  time  after  recovery  (two 
or  three  months). 

The  eosinophilia  appearing  after,  injections  of  tuberculin 
should  also  be  included  in  this  group.  It  must,  however,  be 
mentioned  that,  according  to  Fauconnet's  researches,  this  condition 
cannot  be  regarded  as  proved. 

6.  Malignant  Disease.  —  A  number  of  authors  have 
observed  a  moderate  degree  of  eosinophilia  in  the  cachexia  of 
malignant  disease ;  the  values  do  not  exceed  7  to  10  per  cent,  in 
these  cases.  Eeinbach  only  found  the  eosinophile  cells  increased 
four  times  in  forty  cases  of  this  kind.  The  values  found  were 
.7"8  per  cent,  in  sarcoma  of  the  forearm,  8'4  per  cent,  in  sarcoma 
of  the  leg,  and  11'6  per  cent,  in  an  abdominal  malignant  tumour. 
He  also  recorded  a  case  of  lymphosarcoma  of  the  neck  with 
secondary  growths  in  the  lymphatic  glands,  in  which  an  enormous 
increase  of  the  white  blood  corpuscles  and  especially  of  the 
eosinophile  cells  was  present.  The  absolute  number  of  the  latter 
at  one  time  was  60,000,  which  is  equivalent  to  three  hundred 
times  the  normal  value ;  such  an  increase  has  never  been  seen  in 
any  condition  save  perhaps  leukaemia. 

A  moderate  degree  of  increase  is  not  uncommon  in  the  early 
stages,  especially  of  carcinoma.  The  more  the  cachexia  advances 
the  greater  is  the  tendency  for  the  values  to  sink  below  the 
normal  level. 

In  the  immediate  neighbourhood  of  cancerous  nodules 
veritable  nests  and  collections  of  eosinophile  cells  are  often  met 
with. 

7.  Compensatory  Eosinophilia  (after  elimination  of  the 
spleen). — This  form  of  eosinophilia  has  been  dealt  with  in  detail 
in  the  chapter  on  the  function  of  the  spleen.  It  has  been  pointed 
out  that  the  increase  of  eosinophile  cells  which  has  been  found  by 
Rieder,  Weiss,  and  others  in  chronic  splenic  tumours  may  be 
attributed  to  the  elimination  of  the  spleen.  The  data  with  regard 
to  this  point  need  supplementing. 


THE  WHITE  BLOOD  CORPUSCLES     1G9 

8.  Medicamentous  Eosinophilia. — The  only  observation 
of  thi.s  kind  published  hitherto  was  made  by  von  Noorden.  He 
found  eosinophilia  up  to  0  per  eent.  in  the  blood  of  two  chlorotie 
girls  after  they  had  taken  camphor.  The  phenomenon  could  not 
be  induced  in  other  patients.  An  increase  of  the  eo8inoi>hile8 
can  be  noted  in  connection  with  other  preparations;  in  these 
cases  there  is  always  a  preliminary  decrease.  As  is  the  case  in 
the  post-infective  form  of  eosinophilia,  this  condition  is  un- 
doubtedly due  to  a  toxic  (toxic-infective)  influence  on  the  pro- 
duction of  the  eosinophile  cells  in  the  bone  marrow,  and  not  to 
a  chemotactic  effect.  The  function  and  cell  production  of  the 
marrow  is  first  diminished,  and  after  recovery  takes  place  the 
function  is  likewise  restored  and  may  even  be  increased  above 
the  normal  level.  It  is  possible  that  a  direct  casting  out  of 
eosinophile  cells  occurs  without  any  destruction  of  the  same  in 
the  early  stages,  or  in  other  words  that  there  is  a  negative 
chemotaxis  in  this  case;  but  this  question  requires  further  careful 
investigation. 

9.  Nervous  Eosinophilia. — The  origin  of  this  phenomenon 
is  still  obscure,  but  there  is  no  doubt  that  it  takes  place.  Quite 
considerable  increases  in  number  of  eosinophile  cells  are  seen  not 
infrequently  in  neurasthenia.  The  author  has  found  as  high  a 
value  as  10  per  cent,  in  nervous  diarrhoea  associated  with 
colic. 

The  analogy  with  the  conditions  obtaining  in  bronchial  asthma 
is  so  obvious  that  it  is  unnecessary  to  dwell  upon  it. 

10.  Scarlatinal  Eosinophilia.  —  Scarlatina  is  the  only 
bacterial  infection  which  yields  an  increase  of  the  eosinophiles 
at  the  height  of  the  fever.  This  usually  takes  place  on  the  second 
day  of  the  fever.  As  a  rule,  only  moderately  high  numbers  are 
found,  such  as  500  to  1000,  but  at  times  they  may  be  as  high  as 
2000  or  3000  during  the  acute  stages.  It  is  quite  possible  that 
this  form  of  eosinophilia  is  related  in  some  way  to  the  exanthem ; 
in  scarlatina  without  a  rash  no  increase  is  observed. 

1 1 .  Leukaemic  Eosinophilia. — The  increase  in  the  numbers 
of  the    eosinophile  cells   in  myeloid   leukaemia   is   practically  a 


170  ANAEMIA 

regular  occurxence,  and  the  absolute  numbers  at  all  events  are 
often .  very  high.  This  subject  will  be  considered  in  detail 
subsequently. 

Various  theories  have  been  enunciated  with  regard  to  the 
origin  of  the  polynuclear  eosinophile  leucocytes.  Ehrlich  found 
it  necessary  to  establish  his  view  of  the  bone  marrow  genesis  of 
these  cells  in  the  first  edition  of  this  work  by  the  application  of 
much  ingenuity.  It  is  no  longer  necessary  to  defend  this  view. 
The  theories  which  assume  that  the  eosinophile  cells  are  derived 
from  the  neutrophile  cells  within  the  blood  vessels  are  not 
supported  by  any  histological  evidence.  Such  an  occurrence  can 
never  have  been  observed,  and  this  view  need  therefore  not  be 
taken  seriously. 

The  bone  marrow  genesis  is  quite  clear,  and  may  be  demon- 
strated histologically  by  means  of  modern  section  staining.  As 
is  the  case  with  the  neutrophile  cells,  the  bone  marrow  is  the 
only  site  where  eosinophile  myelocytes  occur  under  normal  con- 
ditions and  in  which  all  the  forms  intermediate  between  the 
myelocytes  and  the  polymorpho-nuclear  cells  are  met  with. 

Several  authors  believe  that  the  eosinophile  cells  can  be  formed 
locally.  This  is,  however,  not  the  case  under  ordinary  conditions. 
The  infiltrations  around  the  trichinee,  the  enormous  peribronchial 
collections  in  asthma,  and  the  collections  in  the  intestinal  walls 
have  been  proved  to  be  chemotactic,  since  only  polymorpho- 
nuclear cells  and  no  myelocytes  are  present.  Mononuclear 
eosinophiles  are,  it  is  true,  seen  in  sputum,  but  these  cells  are 
involution  forms,  for  they  are  not  so  large  as  myelocytes.  The 
nucleus  is  very  small,  and  it  is  not  possible  to  demonstrate  a 
chromatin  network  in  them. 

Nevertheless,  under  quite  exceptional  conditions,  an  extra- 
medullary  genesis  of  the  eosinophile  cells  may  take  place,  but 
not  from  any  chance  connective-tissue  cell.  This  can  only  occur 
in  connection  with  a  vessel,  and  the  formation  takes  place  either 
from  adventitial  cells  or  in  consonance  with  Schridde's  views, 
from  "  cells  of  the  vascular  wall."  Such  formations,  however,  are 
never  exclusively  eosinophile.     They  always  reveal  myeloid  com- 


THE   WHLTK  JJLOOI)  C OKPIJSCLKS     J71 

plexes,  in  whicli  iioutropliilo  chUh  find  even  nucleated  red  cells 
are  also  formed. 

These  extraniedullary  myeloid  I'nci  am  v(;iy  widely  dissemin- 
ated and  fre(|uent  in  the  embryo.  In  some  animals  they  are  also 
met  with  in  the  adult.  They  are  found  in  man  in  infective 
processes,  in  intoxications,  and  in  anremias,  more  especially  in 
leukaemia,  and  may  be  very  extensive. 

That  the  collections  in  bronchial  asthma  are  really  chemotactic 
is  proved  by  the  way  in  which  the  proportional  numbers  of  the 
eosinophile  cells  vary  to  a  large  extent.  According  to  Heineke 
and  Deutschmann,  the  number  of  eosinophile  cells  in  the  blood  in 
bronchial  asthma  sinks  very  materially  after  the  attack.  This 
would  imply  that  a  temporary  functional  eosinophilia  is  present 
which,  as  is  the  case  in  the  analogous  conditions  of  the  neutrophiles, 
can  only  be  the  result  of  an  increased  activity  of  the  bone  marrow. 

The  question  which  cells  produce  chemotactically  active 
substances  out  of  their  disintegration  products  is  a  very  important 
one,  but  is  one  which  cannot  be  decided  at  present  with  certainty. 
The  ordinary  pus  cells  and  the  lymphocytes  do  not  appear  to 
produce  any  such  substances  on  disintegration  ;  on  the  other  hand, 
there  are  many  reasons  for  believing  that  the  dissociation  products 
of  epithelial  cells  and  of  epithelioid  cells  act  chemotactically.  In 
this  way  the  frequent  occurrence  of  eosinophilia  in  the  various 
forms  of  skin  diseases  might  be  explained.  The  same  explanation 
would  hold  good  for  the  appearance  of  local  collections  of  eosino- 
phile cells  in  all  atrophic  conditions  of  the  gastric,  intestinal,  and 
bronchial  mucosa,  and  also  for  the  increase  of  these  cells  in  the 
neighbourhood  of  carcinomata.  A  further  argument  in  favour  of 
this  view  is  the  fact  that  the  eosinophile  cells  are  more  numerous 
in  bronchitis  and  asthma  when  the  secretion  contains  but  few 
pus  cells.  In  the  last  place,  the  observation  made  in  scarlatina, 
that  when  no  rash  is  present  no  eosinophilia  takes  place,  also 
speaks  in  favour  of  this  view. 

On  the  other  hand,  there  is  no  doubt  that  foreign  substances 
circulate  in  the  body  which  are  able  to  exercise  a  positive  chemo- 
tactic influence  on  the  eosinophile   cells.      Goldmann  found  in 


172  ANiEMlA 

sections  of  the  pancreas  which  contained  Proteus  sanguineus,  that 
the  eosinophile  cells  were  markedly  increased  in  number  in  the 
neighbourhood  of  the  encapsuled  parasites,  while  he  sought  for 
these  cells  in  vain  in  other  areas.  Opie  came  across  similar  con- 
ditions in  connection  with  encapsuled  trichinae,  but  Straubli 
emphasised  the  presence  of  interstitial  foci  of  eosinophile  cells 
under  these  conditions. 

Proscher  reported  a  very  striking  condition,  by  producing  an 
eosinophilic  pleurisy  experimentally  by  means  of  extracts  of  the 
tape-worm. 

In  this  connection  the  observations  made  in  the  various  forms 
of  helminthiasis  (see  p.  166)  are  of  considerable  importance.  It 
was  formerly  thought  that  the  action  of  worms  was  a  purely  local 
one.  The  view  that  their  action  is  due  to  toxic  substances  which 
they  produce  is  now  gaining  considerable  support.  Linstow  has 
pointed  out  that  the  general  typhoid  condition,  and  also  the  fatty 
degeneration  of  the  liver  and  kidneys,  i.e.  of  organs  in  which  the 
Trichince  are  not  found,  necessitate  the  assumption  of  a  toxin  in 
trichinosis. 

The  symptoms  produced  by  the  Bothriocephalus  latus  are  now 
regarded  as  being  due  to  a  specially  produced  poison.  Even  the 
ordinary  tape- worms  effect  a  damage  to  the  organism  not  infre- 
quently, and  this  damage  is  to  be  ascribed  to  the  production  of  a 
poison  (Peiper). 

These  considerations  justify  the  deduction  that  tape-worms  not 
only  take  up  substances  from  their  hosts,  but  also  give  off  other 
substances  which  may  be  taken  up  by  the  intestine  of  the  host 
and  which  may  exercise  a  distant  action.  One  sign  of  this  distant 
action,  as  Leichtenstern  has  pointed  out,  is  the  appearance  of 
eosinophilia  of  the  blood.  The  author  believes  that  the  above- 
mentioned  facts  absolutely  exclude  the  possibility  that  the  sub- 
stances which  attract  the  eosinophile  cells  are  identical  with  the 
substances  which  produce  ansemia.  Several  observations,  such  as 
that  of  the  absence  of  eosinophilia  in  BothriocepJialus  anosmia 
(Schauman  and  Naegeli)  point  to  the  probability  of  the  existence 
of  two  separate  functions.     At  all  events,  the  substance  which 


THE  WHITE  15IX)()I)  ClOliPUSCLES     173 

produces  the  eosinopliilia  is  iiiucli  more  widely  distributed  than 
the  substance  wliich  is  responsible  for  the  anjemia. 

In  order  to  consider  how  polynuclear  eosinopliilia  is  pro- 
duced, it  may  be  advisalde  to  have  regard,  in  the  first  place,  to 
an  experiment  wliich  was  performed  by  E.  Neusser.  Neusser 
found  that  the  contents  of  the  bulla'  in  a  case  of  pemphigus  con- 
sisted ahnost  exclusively  of  eosinophile  cells.  The  blood  of  this 
patient  showed  a  considerable  increase  of  eosinophiles.  Neusser 
thereupon  produced  a  non-specific  inflammatory  blister  by  means 
of  a  vesicant,  and  found  that  the  cellular  contents  of  this  blister 
were  exckisively  polynuclear  neutrophile  pus  cells  such  as  are 
met  with  in  all  simple  inflammations. 

Leredde  and  Perrin  met  with  conditions  which  were  absolutely 
analogous  to  those  of  Neusser's  case,  without  the  assistance  of  any 
experimentally  produced  lesions,  in  what  is  known  as  Diihring's 
disease.  The  vesicles  which  occur  in  this  dermatosis  contained 
only  polynuclear  eosinophile  cells  as  long  as  the  fluid  remained 
clear.  In  a  later  stage,  as  is  usually  the  case,  bacteria  invaded 
the  vesicles,  and  when  this  occurred  they  were  found  to  contain 
cells  with  neutrophile  granules  only. 

ISTeusser's  experiment  and  Leredde  and  Perrin's  observations 
can  only  be  explained,  in  accordance  with  the  modern  views  of 
the  nature  of  suppuration,  by  assuming  that  the  eosinophile  and 
the  neutrophile  cells  possess  chemotactic  susceptibility.  This 
view  has  already  been  supported  in  this  work.  According  to  this 
conception,  the  eosinophile  cells  would  only  migrate  towards  those 
sites  which  contain  substances  which  specifically  stimulate  these 
cells.  All  the  experiments  and  clinical  observations  on  eosino- 
pliilia which  have  hitherto  been  recorded  may  be  explained  lege 
arfis  on  this  assumption.  ISTeusser's  experiment  may  be  analysed 
as  follows.  A  substance  is  present  in  the  bullfe  of  the  pemphigus 
ease  which  attracts  the  eosinophile  cells  chemotactically.  The 
eosinophile  cells  which  are  normally  present  in  the  blood  migrate 
from  the  circulation  and  produce  an  eosinophilic  suppuration. 
When  the  disease  is  not  very  severe  the  process  may  be  regarded 
as  being  limited  to  a  great  extent  to  the  localised  phenomenon. 


174  ANJEMIA 

A  totally  different  picture  is  developed,  however,  when  the  disease* 
involves  considerable  areas  of  the  body.  Under  these  conditions 
a  large  quantity  of  the  specific  active  agent  is  taken  up  into  the 
blood  stream  by  diffusion  and  absorption,  and  from  this  situation 
it  exerts  a  strong  chemotactic  action  on  the  physiological  depots 
of  the  eosinophile  cells,  i.e.  on  the  bone  marrow.  This  leads  to  a 
more  or  less  marked  increase  of  the  eosinophile  cells  in  the  blood. 
The  bone  marrow,  in  consequence  of  the  increased  migration,  is 
stimulated  to  produce  more  cells,  in  accordance  with  general 
biological  laws,  and  thiis  retains  the  power,  even  when  the 
disease  lasts  for  a  long  time,  of  keeping  up  a  continuous  eosino- 
philia. 

Other  clinical  experiences  may  also  be  explained  satisfactorily 
in  this  manner.  Gollasch  found  that  the  sputum  of  asthmatics 
only  contains  eosinophile  cells  in  addition  to  Charcot's  crystals. 
It  must  therefore  be  supposed  that  the  interior  of  the  bronchial 
tree  contains  a  substance  which  attracts  the  eosinophile  cells. 
The  close  relationship  which  has  been  shown  by  numerous 
clinical  observations  to  exist  between  the  severity  of  the 
disease  and  number  of  eosinophile  cells  in  the  blood  may  also 
be  regarded  as  pointing  to  this  view,  von  Noorden  was  able 
to  show  that  the  eosinophile  cells  in  the  blood  are  more 
numerous  about  the  time  of  an  attack  than  when  a  considerable 
time  since  the  last  attack  has  elapsed.  They  were  present  in 
especially  large  numbers  when  the  attacks  followed  one  another 
rapidly  during  the  course  of  several  days.  That  the  increase 
in  number  of  the  eosinophile  cells  in  this  case  depends  directly 
on  the  attack  and  is  not  merely  a  sign  of  a  persistent  anomaly 
of  constitution  is  proved  by  a  case  which  von  Noorden  reports. 
During  the  attack  he  found  25  per  cent,  eosinophiles,  while 
a  few  days  later  he  only  found  one  single  cell  in  twelve  cover- 
slip  specimens,  which  means  that  there  was  actually  a  diminution 
of  this  group  of  blood  cell. 

Canon  had  the  same  experience  in  skin  diseases.  He  was 
able  to  show  that  the  degree  of  the  eosinophilia  depended  on 
the  local  extent  of  the   affection  rather   than   on  the  intensity. 


THE  WIHTK   15L()()1)  COIMHJSCLES     17r, 

This  means  thaC  the  eosinophilia  depondH  on  that  factor  whir^h 
determines  the  quantity  of  the  .specific  agent  in  the  blood. 

All  tliose  laws  which  have  heen  described  as  governing 
neutrophile  leucocytosis  ar.;  ai.plicable  in  the  case  of  eosinophile 
leucocytosis  also.  One  of  the  most  important  facts  in  this 
connection  is  that  no  eosinophilia  occurs  when  the  bone  marrow 
function  is  paralysed,  even  if  ('hcniotactically  active  substances 
are  present.  Striiubli  produced  very  severe  experimental 
trichinosis  which  ran  its  course  to  a  fatal  termination  with  a 
complete  absence  of  acidophile  cells;  while  Liermberger's 
ankylostomum  patients  only  showed  low  percentages  of  eosino- 
phile cells  during  a  very  severe  illness.  On  the  application 
of  arsenic  the  number  increased  from  3-2  per  cent,  to  33-7  per 
cent.,  in  spite  of  the  fact  that  the  worms  were  not  driven  out. 
Leichtenstern  noticed  on  a  previous  occasion  that  a  croupous 
pneumonia  in  an  ankylostomum  patient  could  depress  the 
number  of  eosinophile  cells  from  72  per  cent,  to  6  or  7  per 
cent.,  and  that  the  former  values  were  closely  approached  at 
a  later  date  again. 

The  presence  of  chemotactically  active  substances  is  there- 
fore not  to  be  regarded  as  the  final  determining  cause.  A 
capability  of  reacting  on  the  part  of  the  bone  marrow  in 
addition  is  necessary.  The  quantity  of  toxin  may  be  even  too 
large,  as  in  experimental  trichinosis,  so  that  the  eosinophilia 
may  be  partly  or  completely  prevented.  Opie  was  able  to  show 
that  an  overdose  of  the  agent  does  not  produce  a  stimulation 
of  the  marrow,  but  actually  kills  the  cells. 

These  considerations  prove  that  the  eosinophile  curve  records 
the  function  of  an  organ,  and  it  therefore  follows  that  it  is 
quite  impossible  for  the  changes  in  the  blood  and  tissues  to 
depend  on  a  local  histogenic  formation. 

C— Mast  Cell  Leucocytosis 

The  increase  of  this  form  of  white  blood  corpuscle  is 
undoubtedly   rare,    and    with     the    exception    of    the    case    of 


176  ANiEMIA 

leukaemia  this  increase  is  small.  It  must,  however,  be  borne 
in  mind  that  normal  blood  contains  a  very  small  number  of 
these  cells,-  so  that  even  a  triple  or  quadruple  increase  would 
scarcely  be  of  importance  in  consideration  of  the  number  of 
the  other  cells. 

Mast  cell  leucocytosis  has  been  seen  in  the  following  con- 
ditions apart  from  leukaemia.  In  skin  diseases,  in  suffusion 
of  milk  of  the  human  breast  (Unger),  in  urticaria  pigmentosa 
(Sabrazes).  Levaditi  has  produced  mast  cell  leucocytosis  in 
animals. 

The  real  mast  cells  of  the  blood  with  their  characteristic 
polymorphous  form  of  nucleus  must  not  be  confused  with  the 
mononuclear  mast  cells  of  the  tissues,  which  are  often  found 
in  large  numbers  in  chronic  inflammations,  in  indurations  of 
the  lung,  in  skin  diseases,  and  in  inflamed  lymphatic  glands. 
These  latter  cells  are  absolutely  different  structures,  and  possess 
practically  no  relationship  to  the  mast  cells  of  the  blood. 
The  only  character  which  they  possess  in  common  with  the 
blood  cells  is  the  presence  of  basophile  metachromic  granulation. 
The  tissue  cells  have  small  round  nuclei,  which  take  on  the 
stain  of  nuclear  dyes  well. 

The  mast  myelocytes  of  the  bone  marrow,  which  represent 
the  precursors  of  the  blood  mast  cells,  are  quite  different  from 
these  tissue  mast  cells,  and  it  needs  only  slight  histological 
knowledge  to  see  that  an  intimate  connection  between  these 
two  kinds  of  mast  cells  cannot  exist. 


VL— LEUKEMIA,  OR  LEUCOCYTH.ffiMIA 

The  interest  which  the  investigator  and  the  clinician  has 
taken  in  leukaemia  has  not  diminished  during  the  past  ten  years. 
This  is  shown  by  the  innumerable  publications  on  the  subject, 
and  by  the  many  theories  which  have  been  evolved  on  the 
pathogenesis  of  this  remarkable  disease. 

Much  that  has  been  suggested  in  this  connection  has  enjoyed 
but  a  short  life  and  has  soon  been  forgotten.     It  has  been  shown 


THE   WIIITK   HI.OOI)  COIMMJSCLKS      177 

tli;i,t  tli(!  study  of  Liu;  lihjod  mid  its  cells  is  inc;i));i,Mc  oF  llnow  iiig 
light  on  the  genesis  of  tlie  disease,  hut  that  advance  can  only 
be  expected  from  a  most  careful  examination  of  the  organs, 
in  combination  no  doul)t  with  a  iiiiiiut(;  aiudysis  of  cells  in 
the  microscopical  sections  of  thesci  organs.  TJie  icsulls  of  tiiis 
kind  of  investigation  became  so  jdentifid  when  this  was 
recognised  that  our  knowledge  of  leuktemia  thereby  lias  been 
very  materially  extended. 

It  may  be  worth  while  first  to  follow  the  march  of  research 
since  the  discovery  of  lenkicmia.  In  this  way  those  problems 
which  engage  the  attention  of  the  investigator  at  present  will 
present  themselves  automatically. 

At  first  a  lymphatic,  a  splenic,  a  spleno-medullary,  and  a 
pure  medullary  or  myelogenous  form  of  leukcemia  or  leucocythtemia 
were  distinguished  on  the  basis  of  their  clinical  appearances. 
This  classification  depended  on  purely  external  and  gross  signs 
which  could  not  be  recognised  in  hematology. 

Such  a  classification  takes  the  extent  of  the  changes  in 
the  organs  into  consideration  in  the  first  place,  but  not  the 
nature  of  these  changes.  It  ignores  the  most  important  factor 
of  all,- the  kind  of  cell  proliferation. 

Neumann  was  the  first  to  show  that  in  lymphatic  leuktemia 
the  lymphatic  proliferation  is  not  limited  to  the  lymphatic 
glands,  but  may  affect  the  spleen  and  bone  marrow.  These 
proliferation  processes  may  cause  an  enormous  enlargement  of 
the  spleen,  without  any  change  taking  place  in  the  specific 
character  of  the  leukemic  process  or  of  the  appearances  of 
the  blood.  In  spite  of  the  splenic  tumour,  the  case  is  one  of 
lymphatic  leukaemia.  In  ordinary  clinical  terminology  such  a 
case  is  spoken  of  as  "  lymphatic  splenic  leucocy thtemia."  The 
unreliability  and  incorrectness  of  such  a  term  can  best  be  demon- 
strated in  another  form  of  leuksemic  proliferation.  The  liver 
may  become  enlarged  to  the  size  of  a  large  tumour  in  lymphatic 
leukaemia  by  the  production  of  lymphomata,  and  logically 
speaking  this  should  be  termed  a  "  lymphatic  hepatic  leukcemia." 
This  term  would  not  be  so  prone  to  lead  to  error  as  the   term 

12 


178  ANEMIA 

"  lymphatic  splenic  leuksemia " ;  for  no  one  would  imagine  that 
in  the-  former  the  liver  cells  pass  over  into  the  circulating 
blood,  while'  the  latter  term  suggests  that  the  specific  splenic  cells 
take  a  part  in  the  changes  in  the  blood. 

The  recognition  of  a  pure  splenic  form  of  leuksemia  is  to  be 
regarded  as  unjustifiable  from  the  point  of  view  of  hsematological 
and  histological  investigations.  After  what  has  been  said  with 
regard  to  the  physiological  participation  on  the  part  of  the 
spleen  in  the  formation  of  blood,  the  probability  of  a  blood 
change  which  is  specifically  due  to  an  affection  of  the  spleen 
is  almost  excluded.  This  view  has  received  full  confirmation 
from  the  results  of  pathological  investigations. 

There  is  not  a  single  case  in  the  whole  of  the  literature 
of  the  subject  in  which  a  pure  splenic  leuksemia  could  be 
accepted. 

The  conditions  obtaining  with  regard  to  myeloid  leukaemia 
are  similar  to  those  mentioned  above,  in  so  far  as  the  occurrence 
of  myeloid  tissue  in  the  spleen  and  lymphatic  glands  is  con- 
cerned. Since  the  proliferation  of  this  tissue  and  not  the 
accompanying  swelling  of  the  spleen  or  lymphatic  glands  is 
the  specific  factor  in  the  process,  it  follows  that  the  term 
"  spleno-medullary  "  or  "  medullary  lymphatic  "  leukaemia  is  also 
illogical  and  likely  to  lead  to  error. 

Ehrlich  therefore  recognised  from  the  hsematological  stand- 
point two  forms  of  leuksemia. 

1.  Leuksemic  processes  with  proliferation  of  lymphatic  tissue 
— Lymphatic  Leuksemia. 

2.  Leuksemic  processes  with  proliferation  of  myeloid  tissue — 
Myeloid  Leuksemia. 

If  it  be  found  advisable,  there  would  be  no  objection  to 
indicate  the  accompanying  clinical  signs  by  the  addition  of 
words  which  would  not  give  rise  to  misunderstanding ;  for 
example,  "lymphatic  leuksemia  with  swelling  of  the  spleen  or 
of  the  liver,"  or  "  myeloid  leuksemia  with  enlargement  of  the 
lymphatic  glands,"  and  so  on. 

This     classification,     which     was     made     on     the    basis    of 


THE   WTTITR  lU.OOD  CORPUSCLES     170 

cytological  coiiBidonitioiiH,  Iiiis  in-ovail  Lo  Ix;  absolutely  satis- 
factory in  the  light  ol'  Hubsequent  histological  researches. 
The  study  of  the  organs  showod  f(uit(',  dcntiitdy  that  there  are 
only  two  forms  of  leukicinic,  ])rolir(M;i,tioii.  In  tlie  one  form 
the  lymphatic  tissue  and  on  the,  otbci'  tin;  niodulbuy  tissue 
is  aCleeted  in  o()i'res])ondene(;  with  LIk;  bict  tli;it  there  ;tr(;  only 
two  forms  of  tissue  which  form  leucocytes  nornjally.  liefore 
these  aspects  of  this  disease  are  dealt  with  it  may  be  advisable 
briefly  to  survey  its  clinical  manifestations,  since,  in  view  of 
the  radical  differences  of  the  clinical  appearances  of  the  two 
forms  of  leukasmia,  both  should  be  recognised. 

Lymphatic  leuka3mia  may  be  divided  into  two  clinically 
distinct  forms.  First,  acute  lymphatic  leuksemia  may  be 
recognised  by  its  rapid  course,  by  the  small  degree  of  swelling 
of  the  spleen,  by  the  tendency  of  petechial  haemorrhages  to 
appear,  and  by  the  general  hasmorrliagic  diathesis.  This  form 
of  disease  has  given  the  majority  of  clinicians  the  impression 
of  an  acute  infective  process  on  account  of  its  fulminating  course. 

The  second  form  of  lymphatic  leuktemia  is  distinguished 
from  the  preceding  form  by  its  chronic,  frequently  protracted 
course.  The  spleen  usually  participates  in  the  disease,  in 
taking  on  a  very  considerable  swelling.  Hsematologically,  all 
forms  of  lymphatic  leukaemia  are  characterised  by  a  marked 
predominance  of  lymph  cells.  Either  the  small  or  the  large 
lymphocytes  may  be  present,  or  a  variable  mixture  of  both 
forms.  It  must  be  emphatically  pointed  out  that  the  pre- 
ponderance of  large  lymph  cells  is  by  no  means  characteristic 
of  the  acute  form  of  lymphatic  leukaemia,  since  the  same  blood 
changes  are  found  in  very  slowly  advancing  chronic  cases.  In 
a  case  of  this  kind,  which  was  being  treated  in  Gerhardt's  clinic, 
all  the  observers  who  examined  the  blood  (G-rawitz,  von  jSToorden, 
Ehrlich)  were  able  to  find  the  large  cells  during  the  whole 
course  of  illness. 

The  histological  examination  of  the  organs  has  yielded  an 
indisputable  explanation  of  the  origin  of  this  form  of  leukaemia. 
The  foci  of  lymphatic  production  are  not  only  very  extensive, 


180  ANiEMIA 

but,  as  is  proved  by  the  occurrence  of  mitosis,  are  in  a  state  of 
considerable  activity.  The  disease  therefore  depends  on  an 
enormous  increase  in  the  output  of  cells,  and  the  cells  thus 
formed  are  passed  over  to  the  blood  obviously  in  the  same 
way  as  under  normal  conditions. 

Chemotactic  laws  do  not  come  into  play  at  all,  neither  are 
the  cells  passively  washed  out  of  the  organs.  Hyperfunction  of 
the  tissue  is  the  characterising  factor  of  the  process. 

Myeloid  leukaemia  presents  a  picture  which  is  totally  different 
from  every  point  of  view. 

In  former  years  great  difficulty  was  experienced  in  differen- 
tiating between  myeloid  leukaemia  and  simple  leucocytosis ; 
the  two  phenomena  were  even  regarded  as  different  degrees 
of  the  same  pathological  process,  and  it  was  thought  that 
when  the  proportion  of  the  white  to  the  red  blood  corpuscles 
exceeded  a  definite  limit  (1  :  50)  leucocytosis  ended  and 
leukaemia  began.  The  fundamental  differences  of  the  two 
conditions  were  only  recognised  when  the  cells  were  analysed 
with  the  assistance  of  staining  methods.  Leucocytosis  is  now 
recognised  as  a  condition  in  which  the  normal  polynuclear 
neutrophile  leucocytes  are  merely  increased  in  number,  while 
in  myeloid  leukaemia  elements  are  introduced  into  the  blood 
stream  in  large  numbers  which  are  not  normally  present  in  it. 
The  cell  forms  which  are  thus  introduced  into  the  blood  are  so 
characteristic  that  the  diagnosis  of  leukaemia  is  possible  even 
in  those  very  rare  cases  in  which  the  total  number  of  white 
blood  corpuscles  is  not  materially  increased  or  is  actually 
diminished. 

It  is,  however,  necessary  in  cases  of  this  kind  to  exercise  a 
critical  judgment  and  to  rely  on  experience,  since  marked  dis- 
turbances of  leucopoiesis  may  be  present  in  severe  anaemias 
without  the  condition  necessarily  being  leukaemic. 

It  is  possible  with  the  assistance  of  modern  hsematological 
technique,  in  accordance  with  Ehrlich's  principles,  to  recognise 
leukaemia  with  certainty  in  practically  every  case  from  the 
appearance  of  the  blood.     Difficulties  are  only  temporarily  met 


THE  WHITE   HLOOI)  CORPUSCLES     181 

with  in  those  cases  in  which  either  the  disease  is  still  in  a 
very  early  stage — this  stage,  however,  is  very  rarely  seen — or 
when  the  leuk.'cinic  characters  are  temporarily  ohsciired  by  the 
occurrence  of  complications  siK^h  as  a,n  infective  disease. 

The  opposition  to  the  recognition  of  the  changes  in  the  blood 
in  this  disease  has  now  been  finally  removed.  Although  this 
found  its  way  into  the  text-book  on  ha^matology  of  ten  years 
ago  (v.  Limbeck),  the  arguments  used  then  seem  quite  incompre- 
hensible now. 

The  microscopical  appearances  of  myeloid  leukii-mia  are 
characterised  by  an  increase  in  the  number  of  white  blood 
corpuscles,  which  is  almost  always  considerable,  and  by  the 
variegated  and  changeable  character  of  the  cells.  The  latter  is 
due  to  the  complication  of  several  anomalies,  which  consist  in : — 

1.  That  besides  the  polynuclear  cells  their  precursors,  the 
mononuclear  granulated  leucocytes,  the  myelocytes  circulate  in 
the  blood ; 

2.  That  in  the  increase  of  the  white  blood  corpuscles  all 
three  types  of  granules  are  met  with,  i.e.  the  neutrophile,  the 
eosinophile,  and  the  mast- cell  granules; 

3.  That  atypical  forms  of  cells,  e.g.  dwarf  forms  of  various  kinds 
of  white  blood  corpuscles  and  also  mitotic  figures  are  seen  ;  and 

4.  That  the  blood  always  contains  nucleated  red  blood 
corpuscles,  often  in  great  numbers. 

1.  It  is  advisable  to  begin  by  dealing  with  the  Mononuclear 
neutrophile  cells,  Ehrlich's  Myelocytes.  These  cells  are 
present  in  such  large  numbers  in  the  blood  of  medullary 
leukaemia  that  they  give  the  whole  picture,  at  all  events  in 
the  later  stages,  a  predominating  mononuclear  character.  Under 
normal  conditions  the  myelocytes  only  occur  in  the  bone 
marrow,  as  has  been  stated  repeatedly,  and  never  in  the  cir- 
culating blood.  The  signal  diagnostic  importance  of  the  presence 
of  these  cells  is  not  detracted  from  by  the  fact  that  they  occur 
temporarily  in  feome  other  conditions.  Even  if  they  are  found 
as  one  of  the  signs  of  a  general  leucocytosis  in  the  critical 
period  of  a  pneumonia,  it  is    unlikely   that   the   condition  could 


182  ANEMIA 

be  confused  with  the  blood  changes  of  leuksemia.  This  is  safe- 
guarded :  (1)  By  the  much  smaller  increase  of  the  white  cells 
generally ;  "(2)  by  the  diminution  of  the  eosinophile  and  mast 
cells  ;  (3)  by  the  predominating  polynuclear  character  of  the  leuco- 
cytosis,  which  is  not  obscured  by  the  presence  of  a  small  number 
of  myelocytes ;  and  (4)  by  an  incomparably  smaller  absolute 
number  of  myelocytes.  If  Turk's  most  extreme  case  be  taken, 
namely,  one  of  croupous  pneumonia  in  which  the  percentage  of 
the  myelocytes  reached  as  high  as  11 '9  per  cent,  of  the  total 
number  of  leucocytes,  it  will  be  seen  that  the  absolute  number 
of  these  cells  per  cubic  millimetre  was  1000  at  most.  This 
number  is  one  which  cannot  compare  with  the  number  of 
myelocytes  in  leuksemic  blood,  which  may  reach  in  an  average 
and  certainly  not  exceptional  case,  50,000  to  100,000  per  cubic 
millimetre  and  higher. 

Some  difficulty  may  be  experienced  in  connection  with  the 
so-called  atypical  leuksemias.  The  conditions  obtaining  with 
regard  to  this  form  are  so  complicated  that  it  appears  inadvisable 
to  discuss  them  in  detail  in  this  work.  The  author  therefore 
prefers  to  reserve  this  for  a  further  communication  on  the 
subject.  He  also  refers  the  reader  to  the  chapter  dealing  with 
this  subject  in  his  text-book  (page  364). 

2.  The  Mononuclear  Eosinophile  Cells. — Mosler  described 
large  coarsely  granulated  cells,  medullary  cells,  as  characteristic 
of  the  myelogenous  form  of  leukaemia  even  before  the  intro- 
duction of  modern  staining  technique.  These  cells  must  be 
regarded  as  being  to  a  great  extent  identical  with  mononuclear 
eosinophile  cells,  to  which  Mliller  and  Eieder  called  attention 
as  a  special  form  of  cell,  and  which  they  appropriately  described 
as  the  eosinophile  analogies  of  the  myelocytes.  These  cells 
are  large,  rather  bulky  elements  with  oval  nuclei  which  stain 
feebly.  In  spite  of  the  fact  that  these  cells  are  undoubtedly  a 
valuable  sign  of  a  leukasmic  affection,  their  importance  in  the 
diagnosis  of  this  condition  is  not  so  great  as  that  of  the 
mononuclear  neutropliile  cells,  on  account  of  the  numerical 
superiority    of  the  latter.     It  is  not  permissible    to    diagnose   a 


TIIK   WIMTK    VAAH)\)  ( OIMMJSCLKS      \H'4 

leukaemia  alone  from  Llic  pru.senco  of  "  eoHiuoijIiile  myelocyteH," 
becaiLse  they  do  occur,  alhoit  in  small  TiuiribfirH,  in  other 
afCections. 

3.  The  Absolute  Increase  of  the  Eosinophile  Cells. — 
Ehrlich  has  always  iauglit,  since  lie  first  published  his  opinions 
on  leukicmia,  that  the  absolute  numljer  of  the  polyniiclear 
eosinophiles  is  always  much  increased  in  myeloid  leuka-mia. 
This  statement  of  Khrlich's  did  not  remain  uncontradicted,  von 
Limbeck  thus  speaks  of  the  "  alleged  "  increase  of  the  eosinophile 
cells  in  his  text-book.  It  was  chiefly  the  well-known  work  of 
Miiller  and  Kieder  which  stimulated  this  opposition  and  which 
awakened  doubt  with  regard  to  tlie  diagnostic  significance  of 
the  eosinophile  cells.  These  authors,  however,  founded  their 
opposition  on  false  premises. 

Ehrlich  did  not  speak  of  an  increase  in  the  percentage  of 
eosinophile  cells,  but  only  of  an  increase  in  their  absolute 
numbers.  Even  if  a  normal  percentage  of  eosinophiles  is  found 
in  a  case  of  leukaemia,  this  must  indicate  a  great  increase  in 
the  absolute  numbers,  and  Miiller  and  Kieder  would  have  been 
able  to  have  confirmed  Ehrlich's  statements  if  they  had  only 
calculated  the  absolute  numbers  in  their  cases.  Out  of  the 
seven  cases  given  in  the  work  bearing  on  this  subject,  only 
three  are  given  in  sufficient  detail  to  enable  the  absolute 
number  of  the  eosinophile  cells  to  be  calculated.  From  these 
data  the  values  are  : — 

Case  29. — 3-5  per  cent,  eosinophiles  =  14,000  per  c.niin. 
Case  30.— 3-9  per  cent.  „  =     8000 

Case  31.— 3-4  per  cent.  „  =11,000 

Zappert  calculated  that  250  per  cubic  millimetre  was  the 
highest  number  of  eosinophiles  which  could  still  be  considered 
normal.  As  compared  with  this  number,  the  average  of  the 
three  cases  cited,  which  works  out  at  11,000,  is  nearly  fifty 
times  as  great.  In  this  way  the  results  of  Midler  and  Eieder's 
own  counts  fully  confirm  Ehrlich's  statement. 

Since  this  time  a  very  large  number  of  further  observations 


184  ANEMIA 

have  confirmed  the  correctness  of  the  view  that  a  marked 
increase  of  eosinophile  cells  takes  place.  In  exceptional  con- 
ditions, however,  this  increase  may  be  absent,  as  when  the 
disease  is  complicated  by  septic  or  infective  processes,  and  also 
in  the  atypical  and  acute  cases. 

At  the  time  when  Ehrlich  set  up  the  doctrine  of  the 
diagnostic  importance  of  eosinophilia  in  leuksemia,  simple 
eosinophile  leucocytosis  (see  p.  164)  had  not  yet  been  recognised. 
This  was  only  found  at  a  later  date  in  comiection  with  asthma, 
etc.  But  even  this  further  discovery  did  not  overthrow  the 
correctness  of  the  doctrine.  Confusion  between  those  con- 
ditions which  accompany  eosinophilia  and  leukaemia  is  quite 
excluded,  since  there  is  not  the  slightest  resemblance  between 
the  clinical  aspects  of  these  conditions.  But  apart  from  this, 
the  appearance  of  the  blood  offers  plentiful  differentiating 
characteristics.  (1)  The  total  increase  in  the  number  of  white 
cells  rarely  reaches  a  degree  which  could  remind  the  hsemat- 
ologist  of  leuksemic  blood ;  (2)  eosinophile  leucocytosis  is  exclus- 
ively polynuclear;  (3)  mast  cells  and  neutrophile  myelocytes 
are  almost  completely  absent. 

A  further  argument  in  favour  of  the  diagnostic  value  of  the 
absolute  increase  in  the  number  of  eosinophile  cells  is  found  in 
those  cases  which  present  a  blood  picture  which  is  extremely 
like  that  of  leuksemia,  but  in  which  the  diagnosis  of  leukaemia 
can  be  excluded  by  the  absence  of  eosinophile  cells.  An  instance 
of  this  is  found  in  a  case  of  carcinomatosis  of  the  bone  marrow 
described  by  Epstein.  The  blood  in  this  case  presented  an 
appearance  of  anaemia  such  as  is  nearly  always  found  in  leukaemia, 
and  revealed  further  an  increase  of  the  white  cells  similar  to  that 
seen  dn  leukaemia,  with  numerous  neutrophile  myelocytes  and 
nucleated  red  blood  corpuscles.  Every  one  who,  like  Mliller  and 
Eieder,  holds  that  the  number  of  eosinophile  cells  need  not  be 
taken  into  account  in  making  the  diagnosis,  would  have  diagnosed 
this  as  a  case  of  myeloid  leukaemia.  This  was,  in  accordance 
with  Ehrlich's  teaching  and  with  the  actual  state  of  affairs, 
excluded  by  the  absence  of  eosinophile  cells. 


THE   WIiriK   liLOOI)  COKIMJSCLKS      185 

In  view  oi'  all  these  consideratioiiH  il  In  lulvisjihlr;,  in  accord- 
ance with  Ehrlich's  teaching,  to  regard  an  ab.solute  increfiwe  in 
the  numbers  of  eosinophile  cells  as  a  very  important  symptom  in 
the  diagnosis  of  leukseniia,  wliich  actually  Ixjlongs  to  the  nature 
of  the  disease.  Great  caution  should  be  exercised  in  making  the 
diagnosis  in  the  absence  of  this  symptom,  and  it  should  always 
be  borne  in  mind  that  this  indicates  a  very  unusual  condition,  for 
which  some  exjilanation  will  liavc  to  be  found. 

4.  The  Absolute  Increase  in  the  Num,ber  of  Mast  Cells. 
— Mast  cells  are  nearly  always  increased  in  number  in  myohjid 
leuktemia.  It  is  possible  to  count  these  elements  in  leuktemic 
blood  when  the  films  are  stained  by  triacid  or  by  eosin-methylene- 
blue.  When  stained  by  the  former  they  appear  like  polynuclear 
non-granulated  cells,  since  their  granules  do  not  take  on  any 
stain  from  the  triacid  mixture,  and  these  cells  have  therefore 
been  described  by  Uthemann  in  his  dissertation  and  classified  as 
non-granulated  cells.  It  was  only  at  a  later  date  that  Ehrlich 
recognised  them  as  mast  cells. 

The  mast  cells  are  more  easily  recognised  after  staining  with 
Giemsa,  or  still  better  with  Jenner's  stain,  since  the  granules  are  not 
dissolved  in  the  methyl  alcohol  as  they  are  in  watery  solutions. 

The  increase  of  mast  cells  is  an  absolute  and  very  considerable 
one  in  nearly  every  case  of  myeloid  leukaemia.  They  are  usually 
half  as  or  quite  as  numerous  as  the  eosinophiles,  and  at  times  they 
may  even  be  present  in  still  greater  numbers  than  the  latter.  It 
follows  from  this  that  the  mast  cells  increase  at  a  relatively 
higher  rate  than  do  the  eosinophiles,  as  their  normal  percentage 
of  the  total  number  of  the  leucocytes  is  only  about  0-28  per  cent. 
The  diagnostic  value  of  the  increase  of  these  cells  in  myeloid 
leukffimia  is  perhaps  even  more  valuable  than  that  affecting  the 
eosinophile  cells,  especially  because  at  present  no  other  condition 
is  known  in  which  a  marked  increase  of  mast  cells  is  met  with. 

It  must,  however,  be  borne  in  mind  in  this  connection,  that  in 
certain  exceptional  conditions,  such  as  acute  and  atypical  cases, 
the  increase  is  usually  not  present  or  these  cells  may  be  altogether 
absent  from  the  blood. 


186  ANEMIA 

5.  Atypical  Forms  of  White  Blood  Corpuscles. — These 
are :  («)  Dwarf  forms  of  polynuclear  neutrophile  or  eosinophile 
elements.  •  They  were  first  described  in  connection  with 
leukaemia  by  Spilling.  As  a  rule  they  are  merely  small  specimens 
of  normal  polynuclear  cells,  (b)  Dwarf  forms  of  mononuclear 
neutrophile  and  eosinophile  leucocytes.  The  significance  of  the 
dwarf  forms  of  the  leucocytes  in  leuksemia  is  not  yet  sufficiently 
explained,  and  it  is  difficult  to  decide  whether  they  enter  the 
blood  as  small  structures  or  whether  they  become  smaller  in  the 
blood  by  fission  and  by  constriction.  It  is,  however,  more 
probable  that  their  production  was  faulty  from  the  beginning,  in 
correspondence  with  the  overproduction  of  cells,  (c)  Cells  show- 
ing mitosis.  It  was  formerly  believed  that  the  detection  of  mitosis 
in  leuktemic  blood  was  of  considerable  importance,  since  it  was 
held  that  this  phenomenon  signified  that  the  increase  of  the  white 
blood  corpuscles  took  place  in  the  circulating  blood  as  a  result  of 
the  process  of  fission.  This  view  was  defended  more  especially  by 
Lowit.  A  number  of  authors  (H.  F.  Mtiller,  Wertheim,  Eieder) 
have  demonstrated  the  occurrence  of  mitosis,  more  especially  of 
the  myelocytes  in  leuksemia  in  the  circulating  blood.  The 
mitosis,  however,  is  not  of  any  diagnostic  importance.  In  the 
first  place,  it  can  only  be  demonstrated  by  the  application  of 
special  methods ;  and  secondly,  it  is  present  only  in  very  few 
cells.  Miiller  stated  that  he  had  to  examine  many  thousands 
of  white  blood  corpuscles  to  find  one  single  instance.  Only  in  one 
case  did  he  meet  with  somewhat  more  numerous  specimens,  but 
even  then  the  proportion  was  one  nucleus  undergoing  mitosis  to 
several  hundred  leucocytes. 

This  find,  which  must  be  regarded  as  practically  a  negative 
one,  teaches  that  mitosis  only  plays  a  negligible  part  in  the 
increase  of  cells  in  the  blood.  It  is  of  no  value  in  the  diagnosis 
of  leukaemia. 

6.  Myeloblasts.^ — -The  blood  of  every  case  of  myeloid  leu- 
ksemia contains  a  certain  number  of  non-granulated  cells  of  the 
myeloid  system, — myeloblasts  (Naegeli).  These  structures  were 
formerly  confused   with  Ehrlich's   so-called   large    mononuclears 


THE  WHITE   IJEOOI)  COHTUSCLES     187 

(they  can  be  readily  distinguiHlied  i'rom  tliese  by  the  iincleuH)  or 
with  the  lai'<4'e  lymphocytes,  or  else  they  were  all  included  in 
one  elass.  A  more  exact  analysis,  howcjver,  reveals  tliat  tljey 
are  totally  different  cells.  These  cells  stiike  the  experienced 
morphological  investigator  at  once  as  a  s])(!c,i;il  kind  of  cell,  and 
the  marked  essential  correspondence  with  tlio  myelocytes  is 
clearly  noted.  The  points  which  indicate  the  analogy  to  the 
myelocytes  are  the  colour  of  the  staining,  the  size  of  the  nuclei 
and  its  proportion  to  the  protoplasm  of  the  cell.  The  nucleus 
usually  includes  several  nucleoli  (from  two  to  four),  which  are 
well  seen  when  stained  by  Giemsa.  The  protoplasm  is  basophile. 
At  times  early  granulation  of  a  neutrophilic  nature  may  be  seen 
in  these  cells,  and  when  stained  by  Giemsa  and  triacid  stains  a 
large  number  of  every  conceivable  intermediate  form  between 
myeloblasts  and  myelocytes  may  be  met  with. 

It  is  quite  clear  and  obvious  for  many  reasons  that  these  cells 
are  not  lymphocytes.  In  the  first  place,  the  development  of  a 
neutrophile  granulation  proves  that  they  cannot  be  cells  of 
lymphatic  tissue,  since  this  tissue  is  not  capable  under  any 
circumstances  of  producing  neutrophile  granules.  In  the  next 
place,  it  would  be  necessary  to  ascertain  where  the  lymphocytes 
could  come  from,  since  histological  research  shows  that  the 
lymphatic  tissue  is  eliminated  and  substituted  by  myeloid  tissue. 
The  final  proof  against  the  lymphatic  nature  of  these  cells  is 
obtained  by  staining  with  Schridde-Altmann's  dye  mixture. 
These  cells  stained  in  this  way  do  not  show  any  fuchsinophile 
granulation,  which  is  always  present  in  lymphocytes.  There  are 
besides  biological  reasons  for  deciding  that  the  non-granulated 
cells  must  belong  to  myeloid  and  not  to  lymphatic  tissue.  These 
cells  increase  very  extensively  immediately  before  death  and  in 
acute  exacerbations  of  the  disease,  as  Ehrlich  first  noticed  and  as 
will  be  described  later.  It  would  be  most  extraordinary  if  under 
such  conditions  a  lymphatic  cell  production  should  become 
prominent.  Much  more  probable  would  be  the  production  of  the 
least  mature  and  most  indiiierent  form  of  myeloid  cell.  This 
suggestion   has   actually  been  made  by  Turk.     However,  histolo- 


■188  ANEMIA 

logical  tests  must  decide  primarily  in  such  cases,  and  these  tests 
have  decided  that  lymphatic  tissue  does  not  proliferate  in  myeloid 
leukaemia,  but  is  crushed  out  of  existence,  and  that  the  myeloid 
character  of  the  proliferation  is  actually  proved  by  the  presence  of 
large  numbers  of  myeloblasts. 

A  further  argument  in  favour  of  the  view  sketched  above,  and 
one  which  in  the  opinion  of  the  author  is  very  convincing,  is  that 
all  acute  forms  of  myeloid  leukaemia  (see  p.  191)  show  high  and 
steadily  increasing  myeloblast  values  from  the  beginning.  The 
sending  forth  of  such  an  immature  medullary  cell  must  therefore 
be  regarded  as  a  sign  of  exhaustion,  and  of  an  absolutely  pre- 
cipitated cell  formation  of  the  myeloid  tissue. 

Ehrlich  mentioned  these  forms  of  changes  in  leuksemic  blood 
in  the  first  edition  of  this  work,  and  pointed  out  that  such  occurr- 
ences at  times  might  give  rise  to  serious  difficulties  in  the 
diagnosis.  He  wrote  on  page  126  of  the  first  edition  of  this 
work  : — 

,  Zappert  reports  the  case  of  a  patient  who  presented  the 
typical  appearances  of  a  myeloid  leukaemia  in  February  1892. 
Inter  alia,  the  proportion  of  the  white  to  the  red  blood  cells  was 
found  to  be  as  1  :  4'92,  and  1400  eosinophile  cells  per  c.mm. 
(3 '4  per  cent.)  were  found.  The  patient  was  admitted  in  a  very 
pitiable  condition  into  hospital  toward  the  end  of  September  of 
the  same  year  and  died  soon  afterwards.  During  this  period  of 
observation  the  counts  showed  a  ratio  of  whites  to  reds  of  1  : 1"5 ; 
a  percentage  of  0"43  eosinophiles,  the  majority  of  the  mononuclear 
cells  were  free  from  all  traces  of  neutrophile  granulation,  and 
represented  about  70  per  cent,  of  the  white  cells.  Zappert 
emphatically  points  out  that  these  cells  were  not  in  the  least  like 
lymphocytes.  Zappert  found  at  the  post-mortem  examination 
that  the  bone  marrow  was  infiltrated  with  a  large  number  of  non- 
granulated  mononuclear  cells,  while  the  eosinophile  cells  were 
considerably  less  numerous  than  they  usually  are  in  the  bone 
marrow  in  leukaemia.  Dr.  Blachstein,  under  Ehrlich's  direction, 
examined  a  second  case  of  this  kind.  The  patient  had  likewise 
been  under  careful  clinical  observation  on  account  of  a  myeloid 


THE   WHITE   HLOOD  COIMMISCLES     189 

leukfiomia  for  a  long  tiiiio.  During-  his  la«t  slay  in  luispital  the 
examination  could  only  be  carried  out  one  day  before  he  died. 
The  (loath  was  due  to  a  septic  complication.  It  was  found  that 
the  blood  showed  all  the  marked  chjuaclfiiistics  of  leukii-mic 
blood.  There  were  62  per  cent,  polynuclear  ceils  and  17'5  per 
cent,  mononuclear  non-granulated  myelocytes  of  about  the  size  of 
ordinary  myelocytes,  0*75  per  cent,  eosinophile  cells,  and  moderate 
quantities  of  nucleated  red  blood  corpuscles.  The  preponderance 
of  polynuclear  and  the  small  number  of  eosinophile  cells  was 
accounted  for  by  the  presence  of  the  septic  infection ;  on  the 
other  hand,  the  absence  of  granules  in  the  mononuclear  cells  was 
very  curious. 

Both  these  cases  can  only  be  adequately  explained  by  pre- 
suming that  in  certain  terminal  stages  the  organism  loses  the 
power  of  forming  neutrophile  substance.  Analogous  conditions 
occur  in  uon-leuksemic  affections ;  for  example,  in  a  case  of  post- 
hsemorrhagic  anaemia  described  by  Ehrlich.  In  such  cases  it  is 
of  great  importance  to  keep  in  mind  these  rare  cases,  which  are 
usually  not  taken  into  consideration  at  all,  since  this  want  of 
knowledge  could  easily  give  rise  to  gross  errors  with  regard  to 
the  nature  and  origin  of  the  mononuclear  cells,  and  might  lead  to 
the  assumption  of  a  splenic  form  of  leukaemia. 

It  will  be  seen  how  both  these  investigators  adhered  to  the 
myeloid  character  of  the  blood  formation.  Since  this  publication 
a  large  number  of  further  observations  have  been  reported  in  this 
connection  (Naegeli,  Hirschfeld,  Billings  and  Capps,  Warburg, 
von  Jaksch,  Mager  and  Sternberg),  and  minute  histology, 
biology,  and  detailed  morphology  have  proved  concurrently  that 
these  cells  are  not  lymphocytes,  but  really  myeloblasts. 

There  still  remains  one  thing  to  be  proved,  whether,  as 
Ehrlich  and  Helly  have  assumed,  the  myelocytes  have  lost  theii- 
granulations,  or  whether  these  myelobasts  are  to  be  regarded  as 
a  new  form  of  cell,  a  precursor  of  the  myelocytes.  The  latter 
view  is  the  more  favoured  one  at  the  present  date,  for  these  cells 
cannot  be  distinguished  from  the  myeloblasts  which  are  normally 
present  in  the  bone  marrow,  and  the  study  of  the  cells  themselves 


190  ANiEMIA 

shows  that  they  are  young  immature  cells,  because  their 
protoplasm  still  has  a  marked  basophile  reaction,  and  because 
granules  very  frequently  appear  immature  in  young  forms. 
This  has  been  observed  in  cells  with  commencing  neutrophile, 
and  especially  well  marked  in  cells  with  eosinophile,  granulations. 
7.  Nucleated  Red  Blood  Corpuscles. — These  cells  are 
constantly  found  in  the  blood  of  leukaemia.  Their  number  in 
the  various  cases  is  very  variable ;  at  times  they  are  very  sparse, 
and  at  other  times  every  microscopical  field  contains  numbers 
of  them.  The  normoblastic  type  is  the  most  frequent,  but  this 
form  of  cell  is  not  infrequently  found  in  conjunction  with 
megaloblasts  and  intermediate  forms.  Mitosis  has  been  described 
in  the  nuclei  of  the  red  discs  by  various  authors,  but  this  only 
possesses  a  small  theoretical  or  clinical  significance. 

The  occurrence  of  erythroblasts  in  the  blood  of  leuksemia 
might  be  a  specific  phenomenon  of  the  disease,  or  only  a  sign  of 
the  anaemia  accompanying  the  leukeemia.  The  author  is  inclined 
to  adopt  the  former  view,  since  such  a  ])rofuse  occurrence  of 
nucleated  red  cells  has  never  been  observed  in  other  forms  of 
anaemia  of  a  similar  degree. 

These  are  the  individual  characters  of  leukaemic  blood,  on 
which  the  diagnosis  of  the  disease  is  based.  It  must,  however, 
still  be  pointed  out  that  even  if  each  individual  factor  which 
has  been  described  may  be  detected  in  every  case  of  medullary 
leukaemia,  the  manner  in  which  they  appear,  and  their  numeric 
ratio  to  one  another  and  to  the  total  cells  of  the  blood,  vary 
considerably.  Apart  from  the  degree  of  the  increase  in  number 
of  the  leucocytes,  one  case  rarely  resembles  another  as  far  as  the 
other  anomalies  are  concerned.  In  one  case  the  blood  picture 
possesses  a  large  mononuclear  neutrophilic  character;  in  a 
second  case  the  preponderance  of  the  eosinophile  cells  is  most 
striking,  and  in  a  third  case  the  nucleated  red  blood  corpuscles 
predominate.  Again,  the  blood  may  be  overwhelmed  by  mast 
cells.  This  shows  that  there  is  such  a  limitless  number  of  possible 
combinations  that  each  case  must  possess  its  own  individual  type. 
It  is  true  that  the  stages  of  the  disease  differ  markedly  from  one 


THE  WHITE   P>L()()D  COIirUSCEES     Hi  l 

another.     For  example,  tlio  nuiubcr  of  inyolocytes  in  smaller  at 
first,  and  later  on  in(n'oas(}S  steadily. 

It  is  of  especial  importance  to  study  Mm!  clianges  wliicli  liie 
blood  in  medullary  leucocythaimia  und(;in-o(!S  duiiii^-  tiir-  course 
of  an  intercurrent  disease,  and  also  under  tiie  inlluence  of 
successful  treatment  by  arsenic  or  Koent<i;en  rays.  It  has  been 
seen  from  the  exliausLive  investigations  which  Iiave  been  under- 
taken by  A.  Friinkel,  Lichtheim,  Neutra,  Dock,  and  others  on 
this  subject,  that  the  total  number  of  leucocytes  undergoes  an 
extraordinary  decrease  under  the  influence  of  febrile  conditions. 
The  blood  then  alters  its  characters  in  that  the  myehemic  type 
in  all  its  individual  details  is  more  and  more  obscured,  and  the 
polynuclear  neutrophile  elements  become  markedly  predominant. 
The  latter  named  cells  may  reach  percentages  which  are 
usually  only  seen  in  ordinary  leucocytosis,  e.fj.  90  per  cent,  or 
higher. 

The  organs  which  form  the  leucocytes  are  also  changed 
nnder  these  conditions,  and  their  functions  become  more  like 
their  normal  functions.  But  as  soon  as  the  action  of  the  foreign 
stimuH  is  discontinued  the  former  leuksemic  picture  rapidly 
reasserts  itself. 

In  recent  years  an  acute  form  of  myeloid  leukaemia  has  been 
observed,  as  well  as  the  ordinary  chronic  form.  A  number  of 
undoubted  cases  of  this  nature  has  already  been  published,  e.g. 
by  Billings  and  Capps,  Hirschfeld,  Naegeli,  Benjamin  and  Sluka, 
Mager  and  Sternberg,  Ziegler  and  Jochmann,  and  others.  The 
clinical  appearances  have  a  very  close  resemblance  to  that  of 
acute  lymphasmia,  especially  on  account  of  the  marked  hasmor- 
rhagic  diathesis,  the  great  prostration  and  the  not  infrequent 
sudden  onset  of  the  disease.  The  course  is  often  a  stormy  one. 
In  all  undoubted  cases  of  this  kind  the  blood  shows  characters 
which  differ  considerably  from  that  which  is  seen  in  the  ordinary 
form.  It  can  be  recognised  at  once  that  the  condition  is 
abnormal  and  unusual.  Corresponding  to  the  rapid  proliferation 
of  the  cells,  numerous  myeloblasts  appear  in  the  blood  from 
the  beginning,  as  the   most  indifferent,  lowest   type    of  cellular 


192  ANEMIA 

elements,  and  their  number  generally  increases  relatively  and 
absolutely  with  surprising  rapidity.  Nucleated  red  blood 
corpuscles  are  very  often  present  in  large  and  even  in  enormous 
numbers. 

Certain  atypical  conditions  are  frequently  noted,  in  the  blood 
in  connection  with  this  rapid  proliferation.  The  most  common 
variation  Is  the  sparse  presence  or  even  absence  of  the  eosino- 
philes  an  I  of  the  mast  cells.  This  is,  however,  not  regular.  A 
few  observations,  including  one  of  the  author's,  revealed  very 
high  values  for  the  acidophile  cells. 

Histologically,  this  form  of  myeloid  leukaemia  does  not 
show  any  special  characteristics,  as  would  have  been  expected, 
save  that  the  organs  contained  very  large  numbers  of 
myeloblasts. 

It  is  possible  to  form  quite  clear  conceptions  with  regard 
to  the  nature  of  the  leuksemic  conditions.  It  is  true,  the  cause 
of  the  affection  is  still  unknown;  but  the  affection  itself  is 
characterised  by  an  enormous  proliferation  of  myeloid  tissue 
in  all  situations  in  which  such  tissue  is  formed  and  increased. 
The  whole  bone  marrow  is  filled  with  functionating  medullary 
cells  in  the  first  place.  In  the  next  place,  as  in  anaemias  and 
infectious  diseases,  foci  are  formed  in  the  splenic  pulp,  in  the 
centres  of  the  lymphatic  glands,  in  tlie  liver,  in  the  omentum, 
and  in  short  everywhere,  but  always  in  intimate  association  with 
blood  vessels.  According  to  Marchand  and  Naegeli,  this  would 
indicate  a  differentiation  of  the  adventitial  cells  into  myelocytes, 
and  a  development  of  cells  which  had  hitherto  remained  un- 
differentiated ;  while,  according  to  Schridde,  the  cells  of  the 
vascular  wall,  i.e.  the  endbthelial  cells,  which  had  retained  their 
(embryonal  type,  would  develop,  just  as  during  the  embryonal 
period,  to  erythroblasts,  myeloblasts,  and  myelocytes.  In  any 
case,  the  formation  only  takes  place  locally,  and  in  close 
association  with  the  blood  vessels.  Cells  of  the  bone  marrow 
type  can  never  be  formed  from  other  kinds  of  cells,  such  as 
lymphocytes.  This  metaplasia,  or,  in  Schridde's  language, 
heteroplasia,  cannot   be   regarded  as   a  tumour-like  process,  or 


THE  WrilTE   lU.OOI)  CORPUSCLES      lO'J 

like  ii  .Sii,r(;oriiaL().sis  ;  for  Uio  k;i.iih!  riniiiiiLioii.s  iu*;  I'oiiinl  in  iiiuiiy 
forms  of  aMiuniia,  infectious  diseases,  and  to  a  vast  extent,  for 
example,  in  the  curable  pseudo-pernicious  anaemia  of  infants. 
This  disease  is  therefore  a  pathological  but  not  a  tumour-like 
proliferation  of  the  myeloid  tissue.  This  ])roliforation  is  met 
with  in  very  varied  aifections,  but  in  its  highest  devf  lopnient  in 
leukreraia. 

BIBLIOGRAPHY. 

Altmann. —  Ueher  die  Ele7nentaror(janismen  imd  ihre  Bezielnimjen  ztb  den  Zellen, 

Leipzig,  1st  Edition,  1890,  2ud  Edition,  1894. 
Arneth. — Die  netUrophilen  weissen  Blutkoiyerrhen  hei  Infektionskrankheiten, 

Fischer,  Jena,  1904. 
AiiNOLD. — -''Zur  Morphologie  und  Biologie  des  Knochenmarks,"  Virchow's 

Archiv,   vol.   cxl.     "  Ueber    die    Struktur    der    haemoglobinlosen    und 

haeuioglobinhaltigen  Knochenmarkszellen,"  Virchow's  Archiv,  1876,  vol. 

cxliv.     "  Zur  Morpliologie  und  Biologie  der  Mastzellen,  Leukocyten,  und 

Lyniphocyten,"  Munchen.  vied.  JVochenschr.,  1906,  p.  585. 
AscHOFP.— "  Ein  Fall  von  Myelom,"  Miinchen.  vied.  JVochenschr.,  1906,  p.  337. 
AsKANAZY. — "  Der  Ursprung  und  die  Schicksale  der  farblosen  Blutzellen," 

Miinchen.  vied.   JVochenschr.,  1904,  p.  1945.     "  Ueber  amoeboide  Bewe- 

glichkeit  der  Lymphocyten,"  Zierjler's  Zentralhl.,  1905,  No.  22. 
Banti. — Trattato  di  Anatomia  patologica,  Milan,  1906.     "  Uelier  Leukaeniien," 

ZiegWs  Zentralhl,  1904,  No.  1. 
Bauer.^ — •"  Ueber  die  Wirkung  der  sogenannten  Fixationsabszesse,"  T^irchoiv's 

Archiv,  vol.  clvi. 
Beck,   v. — "  Subkutane  Milzruptur,    Mdzexstirpation,    Heilung,"   Miinchen. 

vied.  JVochenschr.,  1897,  No.  47. 
Benjamin  and  Sluka. — "  Zur  Leukaemie  ini  Kindesalter,"  Jalwh.  f.  Kinderh., 

vol.  Ixv.  Appendix,  1907. 
Bezan?on  and  Labbe. — Traite  d'heviatologie,  Paris,  Steinheil.  1904. 
Billings  and  Capps. — "  Acute  myelogenic  Leukreniia,"  Amer.  Journ.,  1903. 
BizzozERO. — "  Sul  midollo  delle  osse,"  II  Morgagni,  1869. 
Brandenburg. — "  Ueber  die  Reaktion  der  Leukocyten  auf  Guajaktinktur," 

Munchen.  vied.  JFocJienschr.,  1900. 
Browning. — "  Observations  on  the  Development  of  the  Granular  Leucocytes 

in  the  Human  Fojtus,"  Journ.  of  Path.,  1905,  vol.  x. 
BucHNER. — "  Untersucliungen  iiber  die  bakterienfeindlichen  Wirkungen  des 

Blutes  und  Blutserums,"  Arcli.f.  Hygiene,  1890,  vol.  x. 
Bucklers. — "  Ueber  den  Zusammenhang  der  Vermebrung  der  eosinophilen 

Zellen  im  Blute  mit  deni  Vorkommen  der  Charcotsclien  Kristalle  in  den 

Faeces  bei  Wurmkranken,"  Miinchen.  vied.  JVocliensclir.,  1894,  Nos.  2  and  3. 
Canon. — "  Ueber  eosinopbile  Zellen  und  Mastzellen  im  Blute  Gesunder  und 

Kranker,"  Deutsche  vied.  JVocliensclir.,  1892,  No.  10. 
CoHNHEiM. — Lectures  on  General  Pathology,  1  and  2,  Berlin,  1877. 

13 


194      .  ANEMIA 

Cred^. — "Ueber  die  Exstirpation  der  kranken  Milz  an  Menschen,"  Langen- 

becFs  Archiv,  1883,  vol.  xxxviii.  (Bibliography). 
Dock. — "The  Influence  of  Comjjlicating  Diseases  upon  JjenksemvA,"  Amer. 

Journ ,  1904. 
DoMARUS. — "Die    Blutbildung   in    Milz    und    Leber   bei    experimentellen 

Anaemien,"'  Arch.f.  exi^.  Path.  u.  Pharm.,  19U8,  vol.  Iviii. 
DoMiNici. — "  Des  elements  basophiles  de  la  inoelle  osseuse,"  Coinpt.  rend.  Soc. 

Biol.,  1899,  vol.  li.     "  Sur  I'istologie  de  la  rate  dans  les  etats  infectueux," 

Arch,  de  me'd.  ex-p.,  1900,  vol.  xii.     "  A  propos  de  la  theorie  du  M.  Ehrlich 

sur  le  plan  de  structure  du  systenie  heinatopoietique  des  mammil'eres," 

Bihliogr.  anat.,  1901,  SujDpl.     "  Sur  le  plan  de  structure  du  systeme  hema- 

topoietique  des  mammiferes,"  Arch.  me'd.  exp.,  1901,  vol.  xiii. 
DoMiNici. — "Sur  le   plan    de   structure   du    systenie   hematopoietique    des 

mammiferes,"  Arch.  g^n.  me'd.,  1906. 
Ehrlich. — Farbenctnalytische    Untersuchungen  zur  Histologie  und  Klinik  des 

Blutes,     Berlin,     1891.      "  Beitrage     zur     Aetiologie     und     Histologie 

pleuritischer  Exsudate,"  Charite'-Annalen,  1880,  vol.  vii.     "  Zur  Kenntnis 

des  akuten  Milztumors,''  ChariU-Annalen,  1882,  vol.  ix.     "  Ueber  schwere 

anaemische  Zustande,"  XI.  Kongress  f.  innere  Medizin,  1892.     "  De-uud 

Regeneration  roter  Blutscheiben,"  Transactions  of  the  Society  of  Charite' 

Medical  Practitioners,  June  10  and  December,  9  1880. 
Ehrlich    (Frerichs).  ■ —  "  Ueber    das     Vorkommen    von     Glycogen     im 

diabetischen  xmd  im  normal  en  Organism  us,"  Zeitschr.  f.  Idin.  Medizin, 

1883,  vol.  vii.  p.  33. 
Ehrlich   and   Lazarus. — "  Die    Anaemia,"   NothnageVs  spez.    Pathologie  u. 

Therapie,  1898,  vol.  viii. 
EiXHORN. — "Ueber  das  Verhalten  der  Lymphocyten  zu  den  weissen  Blut- 

korperchen,"  Inaugural  Dissertation,  Berlin,  1884. 
Epstein.,  J. — "  Blutbefunde  bei  metastatischer  Carcinose  des  Knochenmarks," 

Zeitschr.  f.  klin.  Medizin,  1896,  vol.  xxx. 
Fauconnet. — "Tuberkulose  Prozesse  und  Lymphocyten,"  Deutsches  Arch.  f. 

Min.  Medizin,  vol.  Ixxxii. 
Federmakn. —  "Ueber  Perityphlitis  mit   besonderer   Beriicksichtigung  des 

Verbal  tens  der  Leukocyten,"  Mitteil.  aus  den  Grenzgebieten  der  Medizin 

und  Chirurgie,  vol.  xii.    1903,   and    vol.  xiii.    1904.     "  Was   leistet  die 

Leukocytenuntersuchung  im  Friihstadium  der  Appendicitis  ?  Munchen. 

med.  Wochenschr.,  1904. 
Fischer.,  A. —  Untersuchungen  iiber  den  Bau  der  Cycinophyceen  und  BaJderien, 

Jena,  1897. 
Frankel.  a.,—"  Ueber  akute  Leukaemic,"  Deutsche  med.  Wochenschr.,  1895, 

Nos.  39-43. 
Frankel,  A,  undo.  Benda. — "KlinischeMitteilungen  iiber  akute  Leukaemie," 

XV.  Congress  of  Medicine,  1897. 
Frerichs. — "  Ueber  den  plotzlichen  Tod  und  iiber  das  Coma  bei  Diabetes," 

Zeitschr.  f.  Min.  Aledizin,  1883,  vol.  vi. 
Gabbi. — Die  Blutveranderungen  nach  Exstirpation  der  Milz  in  Beziehmig 

zur   haeniolytischen   Funktion   der   Milz,"   Ziegler's  Beitriige,   vol.    xix. 

part  3. 


THE  WHITE  BLOOD  CORPUSCLES     195 

Gluzinski    and    JlKicmiNHTKiN. — "Myolorna   iiikI     Lcukficmia    lyinplialica 

plasinacellularis,"  /'F'/cn.  Min.   Woclicvurhr.,  I!KJ0,  and  I'Dlviarlu'.n  Anli.J. 

hioL  u.  med.  Wiss.,  1907,  vol.  iii. 
(loriDMANN. — "  Beitrag  zii  der  Lelirevondeiii '  niuli^ncn  \jym])h()Ui,'"Zf;idralht. 

f.  allyevh.  Path,()Jo(jic  it.  jxdholoij.  Atudomie,  1802,  vol.  iii. 
GoLDSCHEiDKU  and   Jakob.  — "  Ueber    die   Variationcn   der    LcukocytoHc;," 

Zeitschr.f.  hliii.  Mediziti.,  1894,  vol.  xxv.  (J>il)liogra])liy). 
GoLLASCH. — "  Zur   Kenntnis    dcs    asthnialisclicii    SpuLuiu.s,"   Forlxcliritie   d. 

Medizin,  1889,  vol.  vii. 
Grawitz   and    (Juunki'-krg. — Die  Zellen   des  mensrhlichen  Bluten  im   idtra- 

violetten  Lichte,  Leipzig,  1906. 
Grawitz. — Klinische  Patholoijie  des  Blutes,  3  Edit.,  Leipzig,  1906. 
Grunberg. — "  Beitriige  zur   vergleichenden  Morphologic   der  Leukocytcn," 

Virchow's  Archiv,  1901,  vol.  clxiii. 
Grunwald. — "Studien  ilber  Zellen  im  Auswurf  iind  in  entziindliclicn  Au.s- 

scheidnngen  des  Mensclien,"  Virchow's  Archiv,  vol.  clviii. 
GiJTiG. — "Ueber    die   Beziehungen   der   Hypeideukocytose    zuni    Knucken- 

mark,"  Berl.  Min.  JVochenschr.,  1905. 
GuLLAND. — "  On   the  Granular  Leucocytes,"  Journ.  of  Fhy.noL,   1896,  vol. 

xix. 
Hahn,   M. — "  Ueber    die    Beziehungen    der    Leukocyten    zur    bakteriziden 

Wirkung  des  Blutes,"  Arch.f.  Hygiene,  1895,  vol.  xxv. 
Hayem. — Du  sawj  et  de  ses  alterations  pathologiques,  Paris,  1889. 
Heineke. — "  Ueber  die  Einwirkung  der  Rontgenstrahlen  auf  innere  Organe," 

Mitteil.  aus  den  Grenzgebieten  der  Medizin  und  Chirurgie,  1904,  vol.  xiv. 

Experimentelle  Untersuchungen  iiber  die  Einwirkung  der  Rontgen- 
strahlen auf  das   Knochenmark,"  u.s.w.    Deutsche  Zeitschr.  f.   Chirurgie, 

1905,  vol.  Ixxviii. 

Heineke  and  Deutschmann.  —  "Das  Verhalten  der  weissen  Blutzellen 
wahrend  des  Asthmaanfalles,"  Manchen.  med.  JVochenschr.,  1907,  No. 
17. 

Helly. — "  Zur  Morphologic  der  Exsudatzellen  und  zur  Spezifitat  der  weissen 
Blutkorperchen,  Ziegler's  Beitrage,  1905,  yo\.  xxxvii.  "Experimentelle 
Untersuchungen  iiber  weisse  Blutkorperchen  und  Exsudatzellen,'' 
Wien.  Min.  JVochenschr.,  1904.     "  Die  liaematopoetischen  Organe,"  Wieu, 

1906,  A.  Holder,  Nothnagelsche  Sammlung.  "  Weitere  Versuche  iiber 
Exsudatzellen  und  deren  Beeinflussung  durcli  Bakterien,"  Zentralbl.  f. 
Balcteriologie,  1905,  vol.  xxxix. 

Hesse. — "  Zur  Kenntnis  der  Granula  der  Zellen  des  Knochenmarks,  bezieh- 

ungsweise  der  Leukocyten,"  Virchoio's  Archiv,  1902,  vol.  clxvii. 
HiRSCHFELD. — "Beitriige  zur  vergleichenden  Morphologie  der  Leukocyten," 

J^irchoids  Archiv,  1897,  vol.  cxlix. 
HoRwiTZ. — "  Ueber  die  Histologic  des  embryonalen  Knochenmarkes,"  Wien 

med.  Wochenschr.,  1904. 
Jakob. — "Ueber  Leukocytose,"  XV.  Kongress  innere  f.  Medizin,  1897,  Zeitschr. 

f.  Min.  Medizin,  vols.  xxx.  and  xxxii. 
Jaksch,    R.   v. — "Ueber  die    Zusanimensetzung  des    Blutes  gesunder    und 

kranker  Menscheu,"  Zentralbl.  f.  Min.  Medizin,  1893,  vol.  xxiii. 


196  ANEMIA 

Jaksch,    v.  —  "  Ueber    die    prognostisclie    Bedeutung    der    bei    crouposer 

Pneumonie  auftretenden  Leukocytose,"  Zentrcdhl.  f.  hlin.  Medizin,  1892, 

No.  5. 
Jaksch,  v.,  and  Kretz. — "Fall  von  Leukaemie,"  Wien.  med.   JVochenschr., 

1908. 
Japha. — "Die  Leukocyten  beim  gesunden  und  ktanken  Saiigling,"  Jahrb.f. 

Kinderh.,  1900,  vol.  lii.  and  1901,  liii. 
Jolly.- — "  Sur  les  mouvements  des  myelocytes,"  Compt.  rend.  Soc.  Biol.,  1901, 

vol.  liii. 
Jones,  Wharton. — Philosophical  Transactions,  1846,  vol.  i.  Fo.  82  (quoted 

by  Scbultze). 
Jordan. — "  Die  Exstir|)ation    der  Milz,    ihre    Indikation  und    Resultate," 

Mitteil.  aus  den  Grenzgebieten  XL,  1903. 
Keuthe.  — "  Ueber     die     f  unktionelle     Bedeutung    der     Leukocyten     im 

zirkulierenden    Blute    bei    verschiedener    Ernalirung,"    Deutsche    med. 
Wochenschr.,  1907. 
KiKODSE.  — "  Die   patliologische  Anatomie  des   Blutes    bei    der   crouposen 

Pneumonie,"  Inaugural  Dissertation,  1890  (Russian)  Abstract,  Zentralhl. 

f.  allgem.  Pathologic  u.  patholog.  Anatomie,  1891,  No.  3. 
KoTHE. — "  Ueber  die  Leukocytose  bei  der  Appendicitis,"  Deutsche  Zeitschr.  f. 

Chirurgie,  1907,  vol.  Ixxxviii. 
Laache. — Die  Anaemie,  Christiania,  1883. 
Labadie-Lagrave. — Traits  des  maladies  du  sang,  Paris,  1893. 
Limbeck,  v. — Orundriss  einer  klinischen  Pathologic  des  Blutes,  2nd  Edition, 

Jena,  1896. 
Lengemann — "  Ueber  die  Eutstehung  der  Leukocytose  imd  von   Zellver- 

scbleppungen  aus  dem  Knochenmark,"  Deutsche  med.  Wochenschr.,  1899. 
Lengemann.  —  "  Knochenmarksveranderungen   als   Grundlage   von   Leuko- 
cytose," U.S.W.,  Ziegler's  Beitrdge,  1901,  vol.  xxix. 
LiERMBERGER. — "  Beitrag  zur  Behandlung  der  Ankylostomiasisanaemie  und 

der  Tropenanaemie,"  Berl.  Min.  TFochenschr.,  1905. 
LiTTEN. — "  Die  Krankheiten  der  Milz  und  die  haemorrhagisclien  Diathesen," 

NothnageVs  spez.  Pathol,  u.  Therapie,  1899,  vol.  viii. 
LoBENHOFPER. — "Ueber   extravaskulare   Erythropoese  in   der  Leber  unter 

pathologischen  und  normalen  Verhaltnissen,"  Ziegler's  Beitrdge,  1908,  vol. 

xliii. 
LoEWiT. — "  Bezieliungen   der    einzelnen    Leukocytenformen    untereinander, 

Leukocytose,  Leukaemie,  Pseudoleukaemie,"  Lubarscli  u.  Ostertag,  Ergeh- 

nisse,  vol.  vii. 
Leredde    and    Perrin.  — "  Anatomie  pathologique    de    la  Dermatose    de 

Dlihring,"  Annal.  de  Dermat.  et  Syphiligraph.,  Ill"'®  Ser.  6,  pp.  281  and 

452. 
Leyden,  E. — "Ueber  eosinophile  Zellen  aus  dem  Sputum  von  Bronchial- 
asthma,"  Deutsche  med.  Wochenschr.,  1891,  No.  38. 
LiCHTHEiM.  — "  Leukaemie    mit   komplizierender    tuberkuloser   Infektioii," 

Vereinf.  wissenschaftl.  Heilkunde  zu  Konigsherg,  February  22,  1897. 
LoEWY,  A. — "  Ueber  Veranderungen  des  Blutes  durcli  thermisclie  Einfliisse," 

Berl.  Min.  Wochenschr.,  1896,  No,  4. 


THE  WHITE  BrX)()I)  (OllPUSCLES      197 

LoKWY,  A.,  and  V.  F.  JtuMtTicii.     "  Uchcr  dcu  lOinllii.s.s  von  Fioljcr  luid  Lciuko- 

cytose    auf    den    Verlanf   von    Inf'cktionHkrankhciten,"    DeuUche   med. 

JVocIunnchr.,   1895,  No.   15.     "  Ziir  I'.ioloj^nc,  rlcr   L(;id<ocvton,"    Virdiovj'H 

Archw,  1898,  vol.  c.li. 
JVl  A(Jioi{,  and  Stkhnhkiu^. --"  Zur   Kennlni.s  (l(!f  akulcn    niyeloidcn  (gcinisclit- 

zclligun)  ljcuka(!ini(!,"  Wian.  Idiii.  Wocheimrhr.,  1900,  No.  19. 
MarOHATSID. — "])er    I'rozeHS   dc.r   Wnnrlhcilinig  init    Kinsclihiss  <\fv  Tfans- 

plantation,"  .DctUache  dhirurgie,  1901,  vol.  xvi. 
May  and  Ghunwald. — "  Ikutriige  zur  Blul,fiirl)ung,"   DeidsrhesArch.f.  Idin. 

Med.,  1904,  vol.  Ixxix. 
Mayer,  S.— "Ueber  die  Wirkung  der  Farbstoffe  Violett  B  und  Neutralrot," 

Sitzumjsher.   d.   deutschen   iiaturwissenschaftL-mediz.    Vereines  f.   Bohrnen, 

"  Lotos,"  1896,  No.  2. 
Meyer,  K. — "  Die   klinische    Bedeutung   der  Eosinophilic,"    Inaugural  Dis- 
sertation, Rostock,  1904. 
Meinertz. — "Beitriige  zur  vergleiclienden  Morphologic  der  farVdosen  Blut- 

zellen,"  Virchoid's  Archiv,  1902,  vol.  clxviii. 
Meyer,  Erich,  and  A.  Heineke — "  Ueber  Blutbildungbei  schweren  Anaemien 

und  Leukaemien,"  Dcutsches  Arch.f.  Idin.  Medizin,  1907,  vol.  Ixxxviii. 
Meyer,  Erich. — "  Beitriige  zur  Leukocytenfrage,"  Milnchen.  med.  Wochenschr., 

1903,  p.  1489. 
Meyek,  Erich,  and  Eieder. — Atlas  der  MinJMikfosJcopiedes  Blutes,  2ndEdition, 

Leipzig,  1907. 
Michaelis  and   Wolff. — "Die  Lymphocyten,"  Deutsche  med.   JVochenschr., 

1901,  No.  38.      "  Ueber  Granula  in  Lymphocyten,"  Virchovj's  Archiv, 

1902,  vol.  clxvii. 

Morawitz. — "  LTeber  atypische  schwere  Anaemien,"  Deutsches  Arch.  f.  klin. 
Medizin,  1907,  vol.  Ixxxviii. 

Morawitz  and  Rehn. — "  Ueber  einige  Wechselbeziehungen  der  Gewebe  in 
den  blutbildenden  Organen,"  Deutsches  Arch.  f.  klin.  Medizin,  1907, 
vol.  xcii. 

MosLER. — Die  Pathologic  und  TherajJie  der  Leukaemie,  Berlin,  1872. 

MtJLLER,  H.  F. — "  Zur  Leukaemiefrage,"  DeiUsches  Arch.  f.  klin.  Medizin,  vol. 
xlviii.  "  Ueber  die  atypische  Blutbildung  bei  der  progressiven  perniciosen 
Anaemic,"  Deutsches  Arch.  f.  klin.  Medizin,  1893,  vol.  li.  "  Zur  Lehre 
vom  Asthma  bronchial,"  Zentralbl.  f.  cdlgem.  Pathologie  «.  patholog. 
Anatomie,  1893,  vol.  iv. 

MuLLER,  H.  F.,  and  Rieder. — "  Ueber  Vorkommen  und  klinische  Bedeutung 
der  eosinophilen  Zelle  im  zirkulierenden  Blute  des  Menschen,"  Deutsches 
Arch.f.  klin.  Medizin,  vol.  xlviii.  "  Ueber  einen  bisher  nicht  beachteten 
Formbestandteil  des  Blutes,"  Zentrcdhl.  f.  cdlgem.  Pcdhologie  u.  patholog. 
Anatomie,  1896,  p.  929.  "  Die  Morphologic  des leukaemischen  Blutes  und 
ilire  Beziehungen  zur  Lehre  von  der  Leukaemie"  (zusammenfassendes 
Referat),  Zentralbl.  f.  allgem.  Pathologie  u.  patholog.  Anatomie,  Nos.  13  and 
14,  vol,  V. 

Naegeli. — "  Die  Leukocyten  beim  Typhus  abdominalis,"  DeiUsches  Arch.  /. 
klin.  Medizin,  1900,  vol.  Ixvii.  "Ueber  rotes  Knochenmark  und 
Myeloblasten,"  Deidsche  med.  JVochenschr.,  1900.     "  L^cber  die  Funktion 


198  ANtEMIA 

und  Bedeutniig  des  Knochenniarks,"  KorrespondeMzbl.  f.  Schiveizer  Aerzte, 
1901.  "Die  Prinzipien  der  morpliologisclien  Blutnntersuchnngen," 
ibid..  1905.  "Beitrage  zur  Embryologie  der  blutbildenden  Organe," 
Verhandl.  d.  Koncjr esses  f.  innere  Medizin,  1906.  Bluthrmkheiten  und 
Blutdiagnostilc,  Lehrbitch  der  inoiyhologischen  Haematologie,  Leipzig, 
Veit  &  Co.,  1908. 

Neumann,  E. —  "XJeber  Blutregeneration  und  Blutbildung,"  Zeitschr.  f. 
Idin.  Medhin,  1881,  vol.  iii.  "  Farblose  Blut-  und  Eiterzellen,"  Serl. 
Jclin.  JVochenschr.,  1818,  No.  41.  "Ein  neuer  Fall  von  Leukaemie  mit 
Erkrankung  des  Knochenmarks,"  Arch.  d.  Heilhunde,  1872,  vol.  xiii. 
"  Haematologische  Studien,"  Virchoiv's  Archiv,  1896,  vol.  cxliii.,  1903, 
vol.  clxxiv. 

Neutra.^ — "Ueber  den  Einfluss  akuter  Infektionskrankheiten  auf  die 
Leukaemie,"  Zeitschr.  f,  Heilhmde,  1903,  vol.  xxiv. 

Neusser. — "  Ueber  einen  besonderen  Blutbefund  bei  uratischer  Diathese," 
TVien.  hlin.  Wochenschr.,  1894,  No.  39.  "  Kliniscli-haeraatologische  Mit- 
teilungen  (Pemphigus),"  Wien.  Min.  Wochenschr.,  1892,  Nos.  3  and 
4. 

NooRDEN,  v.- — "  Untersuchungen  liber  schwere  Anaemie,"  Charite'-Anncolen, 
1889,  vol.  xvi.  "Beitrage  zur  Pathologic  des  Asthma  bronchiale," 
Zeitschr.  f.  Min.  Medizin,  vol.  xx. 

Opie. — "The  Occurrence  of  Cells  with  Eosinophile  Granulation  and  their 
Eelation  to  Nutrition,"  ylme?-.  Journ., 1904,  p.  217.  "  An  Experimental 
Study  of  the  Relation  of  Cells  with  Eosinophile  Granulation  to  Infection 
with  an  Animal  Parasite  (Trichina  sjjiralis),"  Amer.  Journ.,  1904, 
p.  477.  "  The  Relation  of  Cells  with  Eosinophile  Granulation  to  Bacterial 
Infection,"  Amer.  Journ.,  1904,  p.  988. 

Pappenheim.- — "  Die  Bildung  der  roten  Blutscheiben,"  Inaugural  Disserta- 
tion, Berlin,  1895  (Extensive  Bibliography).  "  Zur  Verstandigung," 
Virchow's  Archiv,  1901,  vol.  clxiv.  "  Neuere  Streitfragen  aus  dem 
Gebiet  der  Haematologie,"  Zeitschr.  f.  Min.  Medizin,  1902,  vol.  xlvii. 
"Von  den  gegenseitigen  Beziehungen  der  verschiedenen  farblosen. 
Blutzellen  zu  einander,"  Virchoiv's  Archiv,  1900,  vols.  clix.  and  clx., 
"Atlas  der  menschlichen  Blutzellen,"  Jena,  1905.  Folic:  haematologica, 
Internationales  Zentralorgan  fiir  Blut-  und  Serumforschung,  1904- 
1908,  vols.  i.-v.  (Excellent  survey  and  discussion  of  the 
whole  of  the  recent  literature.)  "  Die  Stellung  der  akuten 
grosszellig-lymphocytaren  Leukaemie  im  nosologischen  System  der 
Leukaemien,"  Fol.  haem.,  1907,  vol.  iv.  "  Ueber  akute  myeloide  und 
lymphadenoide  makrolymphocytare  Leukaemie,"  Fol.  haem.,  1908, 
vol.  V. 

Proescher. — "  Ueber  experimentelle  Erzeugung  von  Lymphocytenexu- 
daten,"  Virchow's  Archiv,  1905,  vol.  clxxix. 

Prowazek. — "  Vitalfarbungen  mit  Neutralrot  an  Protozoen,"  Zeitschr.  f. 
ivissenschaftl.  Zoologie,  1897. 

Przesmycki.^ — "  Ueber  die  intravitale  Piirbung  des  Kernes  imd  des  Proto- 
plasmas,"  Biolog.  Zentralbl.,  vol.  xvii.  Nos.  9  and  10.  (Full  Bibliography 
on  granule  staining.) 


TIIK   WHITE   HLOOI)  (OUIM'SCLKS     V.)'.) 

RWJICZKII.-  -"  J)aH  Ycrlmlicu  (1(!S  UIuLoh  ln-.i  Musoi'ii  uri'l  Si;li;irla<;li  iiii 
Kiii(Ie;-»!ilter,"  Zntuchr.  f.  kiln.  Madizin,  \m2,  vo].  xlv.  "  D;in  Vr;rli;i!ten 
der  wcLsscuL  J'.lnLkiii'ix'.rc-lHfii,  l)(!HT)ii(lor.s  dcr  (iosiiiopliilcii  Zcllen,  bei 
einigciii  ErkninkuugciU  dei'  II;miI,  imd  li.u  iMiVktion.-ikrankheiten," 
Deutsches  Arch,./.  Idin.  Med'lziii,,  I'JU'.i,  vol.  Ixxvii. 

RiEDER. — Atlas  der  Idin.  Mikroskopie  den  JUules,  Leipzig,  18'.)'.'.  /kitrHfjc  zur 
Kenntnis  der  Leukorytose  (Bibliography),  Lcij)zig,  \8U2. 

Reinbach. — "  Uebcr  da.s  Vcirlialtcu  der  Leukocytcn  l^ci  iiiuligin-u  'J'luiiorcii," 
Lamjenheck'n  Archiv,  1893,  vol.  xlvi. 

Reinert. — Die  Zdhluwj  der  roten  Blutkoiyerchen.,  Leipzig,  1801. 

RodEU  and  JosNE. — "Lamoelle  osseiisea  I'etat  iioriiial  cL  dans  le.s  infections," 
Suite  des  Mo'iinyraphien,  21,  1899. 

RoiETZKY,  V. —  "Contributions  ^i  retude  de  la  fonction  lieinatopoietique  de 
moelle  osseuse,"  Arch.  de.  scienc.  biol.,  Petersburg,  1877,  T.  V, 

Rosin  and  BiBERGEiL. — "Das  Verhalten  der  Leukocyten  bei  der  vitalen 
Blnti'iirhnng,"  Virchow's  Archiv,  1904,  vol.  clxxviii.  "  Ergebnisse  vitaler 
Blutftirbuiigen,"  Deutsche  med.  Wochenschr.,  1902. 

Sadler. — "  Kliuische  Untersucliungen  liber  die  Zahl  der  corpusculuren 
Eleniente  und  den  Haemoglobiiigelialt  des  Blutes,"  Fortschritte  d. 
Medizin,  1892. 

ScHLEiP. — "  Die  Homberger  Tricbinosisepidemie  und  die  fiir  Tricliinosis 
pathognomonische  Eosinopbilie,"  Deutsches  Arch.  f.  klin.  Medizin,  1904, 
vol.  Ixxx.  Atlas  der  Blutkranklieiten,  Urban  u.  Schwarzenberg, 
1907. 

ScHiNDLER. — "  Untersucbungen  iiber  das  Auftreten  der  Myelocyten  im 
Blute,"  Zeitschr.f.  klin.  Medizin,  1904,  vol.  liv. 

ScHRiDDE. — "Die  Kornelungen  der  Lymphocyten  des  Blutes,"  Munchen. 
med.  Wochenschr.,  1905.  "  Die  Wanderuugsfiiliigkeit  der  Lymphocyten," 
Miinchen.  med.  Wochenschr.,  1905.  "  Die  Darstellung  der  Leukocyten- 
kbrnelungen  ini  Gewebe,"  Ziegler's  Zentrcdbl.,  1905.  "  Studien  iiber  die 
farblosen  Zellen  des  inenschlicben  Blutes,"  Munchen.  med.  Wochenschr., 
1906.  "  Beitrage  zur  Lehre  von  den  Zellkornelungen,"  Anatora.  Hefte, 
1905,  vol.  xxviii.  "  Ueber  Myeloblasten  und  Lynipboblasten,"  Berl.  klin. 
Wochenschr.,  1906.  Transactions  of  Mediccd  Congress,  1906  ;  and 
Ziecjler's  Beitrage,  1907,  vol.  xli.  "  Ueber  die  Herkunft  und  Entsteliung 
menschlichen  Blutzellen,"  Zcitschr.  f.  drztl.  Fortbildung,  1907.  "  Die 
Entsteliung  der  ersten  embryonalen  Blutzellen  des  Menschen,"  VerhandL 
d.  deiUsch.  Pathol.  Gesellsch.,  1907. 

ScHULTZE,  Max. — "Ein  heizbarer  Objekttiscli  und  seine  Verweudung  bei 
Untersuchung  des  Blutes,"  Archiv  f.  mikrosko}}.  Anatomie,  1865, 
vol.  i. 

ScHULTZE,  0. — "Die  vitale  Methylenblaureaktion  der  Zellgranula,"  J.?(a<o??!. 
Anzeiger,  1887. 

ScHUR  and  Lowy. — "  Ueber  das  Verlialten  des  Knochenmarkes  in  Krank- 
heiten  nnd  seine  Beziebungeu  zur  Blutbildung,"  Zeitschr.  f.  klin. 
Medizin,  1900,  vol.  xl. 

Schumacher. — "Ueber  Phagocytose  und  die  Abfulirwege  der  Leukocyten 
in  den  Lyinphdriisen,"  Archiv  f.  mikroskop.  Anat.,  1899,  vol.  liv. 


200  ANEMIA 

ScHULTZ,  EuGEN. — "  Ueber  umkelirbare  Entwicklungsprozesse,"  Vortrdge  u. 

Aufscitze  iiher  EntwicMungsm.echanik  der   Organismen,    Part  4.    Leipzig, 

1908. 
Spilling,  see  Ehrlich,  Farbenanaly tische  Untersuchungeii. 
Staehblin. — "  Blutuntersuchungen  bei  einem  Falle  von  Milzexstirpation," 

Deutsches  Arch.  f.  hlin.  MecUzin,  1903,  vol.  Ixxvi. 
Sternberg. — "  Pathologie  der  Priniarerkrankungen  des  lympliatischen  und 

haemopoietisclien  Apparates,"  Normale  und  pathologische  Morphologic  des 

Blutes,  Wiesbaden,  1905. 
Stienon. — Becherches  sur  la  leucocytose   dans   la  Pneumonie   aigue,  Brussels, 

1895.     De  la  leucocytose  dans  les  maladies  infectieuses,  Brussels,  1896. 
SoNNENBURG.  —  "  Leukocvtenzahlungen,"   Deutsche  med.   Wochenschr.,   1906, 

p.  1604.    "  Weitere  Beobachtungen  ilber  die  Verwertbarkeit  der  Leuko- 
cvtenzahlungen bei  der  akuten  Appendicitis,"  Archiv  f.  hlin.  Ghirurgie, 

1906,  vol.  Ixxxi. 
Staubli. — "Klinisclie  und  experimentelle  Untersuchungen  iiber  Trichinosis 

und   liber   die   Eosinophilie  im  allgemeinen,"   Deutsches  Arch.  f.  hlin. 

Medizin,  1905,  vol.  Ixxxv. 
Studer. — "  Ueber  das  Verhalten  der  weissen  Blutzellen  unter  der  Einwirk- 

ung    von   Typhus    und    Colitoxinen,"   Inaugural  Dissertation,   Zurich, 

1903. 
Teichmann. — "  Mikroskopische  Beitrage  zur  Lehre  von  der  Fettresorption," 

Inaugural  Dissertation,  Breslau,  1891. 
Troje. — "  Ueber  Leukaeniie  und  Pseudoleukaemie,"  Berl.  hlin.  TVochenschr., 

1892,  No.  12. 
TsCHiSTOWiTSCH.  — "  Sur   la    quantite    des    leucocytes    du    sang    dans    les 

pneumonies  fibrineuses  a  issue  mortelle."     Abstract,  Zentralbl.  f.  d.  med. 

fVissensch.,  1894,  No.  39,  and  Annales  Institut  Pasteur.,  1892. 
Turk. — Klinische   Untersuchungeii   iiber   das   Verhalten  des  Blutes  bei  ahiiten 

Infehtionskranhheiten,    Vienna    and    Leipzig,    1898.       Vorlesungen  uber 

klinische     Haematologie,     Vienna,     1904.      "  Ueber     die     Beziehungen 

zwischen  myeloidem  und  lymphoidem    Gewebe  im  Verlauf  von   Leu- 

kaemien,"  Verhandl.  d.  Kongresses  f.  innere  Medizin,  1906. 
Unger.— "  Das  Colostrum,"  Virchow's  Archiv,  1898,  vol.  cli. 
Unna.— "  Plasmazellen,"  Biolog.  Abteil.  d.  artzl.  Vereins  Hamburg.     Abstract, 

Munchen.  med.  Wochenschr.,  1902,  p.  817. 
Uskoff's  and  his  Pupils'  work,  see  especially  Archiv  des  sciences  biolog.  St. 

Petersburg. 
Uthemann. — "  Zur  Lehre  von  der  Leukaemie,"  Inaugural  Dissertation,  Berlin, 

1888. 
ViRCHOW. — "  Weisses  Blut  (Leukaemie),"  Virchow's  Archiv,  vol.  i.  "Cellular- 

pathologie,"  4th  Edition,  Berlin,  1871. 
Waldstbin. — "  Beobachtungen  an  Leukocyten,"  u.s.w.,  Berl.  hlin.  Wochenschr., 

1895,  No.  17. 
-Warburg. — "  Fall  von  Leukaemie."     Abstract,  Munchen.  med.   Wochenschr., 

1906,  p.  1493. 
Wassermann.  — "  Pneumokokkenschutzstoffe,"    Deutsche    med.    Wochenschr., 

1899. 


THE  WHITE  in.OOl)  (ORPUSCr.ES     201 

Wkidenrbich. — "  Studien    iiber    duH    Jiiut,"    u.h.w.,    Archiv   f.    'fidkroHhrq). 

Anat.,  1904,  vol.  Ixv.     "  Ueljer    die  EntHtchung  der  weissen  Blutkor- 

pcrclien  iiii  iKwtfoeialen  Leljcu,"  Anat.  AwMigcr,  1905,  xxvii.  Appendix. 
Wiciss. — IJae'iiudoloyiKcJui  UidernHch/iimjeii,  Vieinui,  1  HOG. 
Wil-iitAMSON.    -"  lU.'bur  daH  Vci'lialteu  dcr  Loukocyliose  ]h:\  dcr  I'liciiiiiokok- 

ki'iicrkruTdvung  der    Kaniiiclicii   mid   de.s   McnHclicii,"  Zingkr's   /lciir('i;/e, 

1901,  vol.  xxix. 
WoJiKK,    A.-  "Di(!  eosinopliilon  Zcllcn,  ilir   Vorkdiiiiinn    imil   ilnc  B(;deiil- 

ung,"  Zieijkr^  Beitniye,  1900,  vol.  xxviii. 
WoIjFF,  a. — "  Ueber  die  Bedeulung  dcr  l^yinplioid/.cllo  bei  dor  nonualen 

Blutbildung  und   bei  der  Leukaemie,"  ZeiUchr.  /.  kli'ii.  Medizin,  1902, 

vol.  xlv.     "  Ueber  die  aktive  Bewegliclikeit  der   Lymphocyten,"  Berl. 

hlin.   JVochenschr^,  1901.     "Ueber  Leukocytengraniilationen,"  ^ei7.s-cAr. /. 

klin.  Medizin,  1904,  vol.  lii. 
Wolff  and  Torda'y. — "  Ueber  die  experimentelle  Erzeugung  von  Lymidio- 

cytenexsudaten,"  Berl.  klin.  JVoclienschr.,  1904. 
Zappert,    J.  — "  Ueber    das     Vorkommen     der     eosinoiiliilen     Zellen     im 

auaemischen  Blute,"  Zeitschr.f.  klin.  Medizin,  vol.  xxiii.  (Bibliography). 

Neuerliche   Beobachtungen  iiber   das  Vorkommen  des  Ankylostomum 

duodenale  bei  den  Bergleuten,"  Wiener  klin.  Wochenschr.,  1892,  No.  24. 
Zesas,    G.— "  Beitrag   zur   Kenntnis    der   Blutveranderung  bei  entniilzten 

Menschen  und  Tieren,"  Langenheck^s  Archiv,  1883,  vol.  xxviii. 
ZiEGLER,  K. — Experimentelle  und  klinische  Untersuchungen  iiber  d,ie  Histogenese 

der  myeloischen  Leukaemie,  Jena,  Fischer,  1906. 
ZiEGLER,  K.,  and  Schecht. — "  Untersuchungen  iiber  die  leukocytotiscten 

Blutveriinderungen  bei  Infektionskrankheiten,"  Deutsches  Archiv  f.  klin. 

Medizin,  1908,  vol.  xcii. 
ZiEGLER  and  Jochmann. — "  Zur  Kenntnis  der  akutenmyeloiden  Leukaemie," 

Deutsche  med.  Wochenschr.,  1907. 
ZoLLiKOPER. — "  Die  Jodreaktion  des  Blutes,"  Inaugural  Dissertation,  Berne, 

1899. 


CHAPTER   IV 
THE  BLOOD  PLATELETS:    HiEMOCONIA 

A  THIED  formed  element  of  normal  blood,  the  blood  platelets,  was 
first  described  by  Hayem  and  later  by  Bizzozero.  These  cells  are 
round  or  oval  discs  without  any  haemoglobin.  The  form  is 
extremely  susceptible  to  mechanical,  thermic,  and  chemical 
influences.  These  cells  measure  about  3  |a<  in  diameter.  A 
marked  characteristic  of  these  cells  is  the  tendency  to  form 
largish  clump  "  bunches  of  grapes,"  which  is  due  to  their  extra- 
ordinary stickiness.  This  peculiarity  renders  it  particularly  easy 
to  distinguish  them  from  other  formed  elements  of  the  blood,  but 
at  the  same  time  it  renders  all  exact  study  and  counting  ex- 
tremely difficult.  When  the  apparatus  which  is  usually  employed 
for  counting  blood  cells  is  used  to  count  these  cells  the  results  are 
quite  unreliable,  since  the  blood  platelets  rapidly  adhere  to  the 
walls  of  the  vessels.  All  the  earlier  authors  attempted  to  get 
over  this  difficulty  by  employing  a  special  diluting  fluid  (14  per 
cent,  magnesium  sulphate  solution — Bizzozero),  which  prevents 
the  clumping  of  the  platelets,  but  a  few  cells  adhered  even  to  the 
glass  walls  of  the  capillary  tube  in  which  the  dilutions  are  made. 

Brodie  and  Ptussell  recommended  a  mixture  in  which  the  blood 
platelets  remained  permanently  isolated  and  in  which  they  could 
be  stained.  They  allow  a  drop  of  blood  to  fall  directly  into  a  drop 
of  the  solution  and  then  determine  the  relative  proportions  of  red 
cells  to  blood  platelets.    Their  solution  was  made  up  as  follows : — 

Dahlia  glycerine,  and 

2  per  cent,  sodium  chloride  solution,  in  equal  parts. 

Sahli  added  a  sufficient  quantity  of  methyl- violet  to  Bizzozero's 
magnesium-sulphate  solution  to  make  a  perfectly  clear  fluid  when 

202 


THE  IVLOOD  PLATELETS:  H/KAJOCONLX   20?, 

placed  ill  a  1.0  c.c.  ino;iHiae  cyliii(l(;r,  luid  ujiowcd  ;i  drop  of  LliiH 
ihnd  lo  fall  on  the  slcin.  He  pricked  the  Kkin  lJiioiiii;}i  the  dro(), 
so  th.'dj  th(!  blood  on  isHuin'j,'  IVoni  tin;  piick  nnxf-s  ;iL  onco  with 
the  solution,  lie;  th(;n  (hitei-mined  the  relative  )»rop(jrtion.s  of  the 
platelets  to  the  blood  coi'puscles.  ILelber  used  a  fresJdy  ]n'e]>ared 
10  per  cent,  solution  of  sodium  lucta-phosphate  to  dilute  the 
blood. 

Another  method  is  the  relative  counting  of  the  blood  platelets 
in  stained  dry  films.  This  method  has  been  employed  by  the 
majority  of  observers  in  recent  times.  Ehrlich  found  that  in 
specimens  treated  by  the  iodine  eosin  method  (see  p.  53)  the  blood 
platelets  are  conspicuous  by  their  intense  red  colour,  which  corre- 
sponds to  the  high  alkali  content  of  these  elements,  and  in  this 
way  they  can  be  easily  counted. 

Biirker  recommended  a  sort  of  accumulation  method  for  the 
purpose  of  obtaining  these  cells  for  examination.  He  allowed  a 
drop  of  blood  to  fall  on  a  smooth  surface  of  paraffin,  and  then 
placed  the  paraffin  in  the  moist  chamber.  The  heavier  erythro- 
cytes and  leucocytes  soon  sedimented,  while  nearly  all  the  blood 
platelets  were  found  on  the  surface  of  the  drop  after  about  twenty 
to  thirty  minutes.  They  were  easily  picked  up  on  to  a  cover 
glass,  and  then  examined  directly. 

Levaditi,  Eosin  and  Bibergeil,  Puchberger,  and  later  on  a  large 
number  of  other  observers  employed  another  method.  A  drop  of 
a  weak  alcoholic  solution  of  a  dye  {e.g.  brilliant  cresyl-blue)  was 
allowed  to  dry  on  a  cover-slip,  and  the  blood  was  received  directly 
on  this  cover-slip.  More  recently  Eomanowsky-Giemsa's  staining 
has  been  employed  with  good  results  for  the  study  of  blood  platelets. 

No  reliable  results  have  as  yet  been  obtained  in  the  counting 
of  these  elements,  either  with  regard  to  their  relative  or  their 
absolute  numbers.  The  normal  values  have  been  fixed  at  200,000 
to  300,000  by  Ebner,  635,000  by  Brodie  and  Eussell,  730,000  to 
962,000  by  Kemp.  From  this  it  will  be  seen  how  little  value  can 
be  attached  to  counts  in  cases  of  disease  at  present,  and  conse- 
quently how  misleading  any  deduction  must  be  when  based  on 
such  counts. 


204  AN.^M1A 

Deetjen  has  described  a  special  method  of  studying  the 
platelets.  "  5  grms.  of  agar-agar  are  dissolved  by  boiling  for  a 
half-hour  in  500  grms.  of  distilled  water,  and  the  solution 
while  still  hot  is  filtered  through  a  folded  filter  paper,  through 
which  it  passes  readily  without  using  a  hot  filter  funnel.  0-6  grm. 
of  NaCl,  6  to  8  c.c.  of  a  10  per  cent,  solution  of  ]SraP03,  and  5  c.c. 
of  a  10  per  cent,  solution  of  KgHPO^  are  added  to  each  100  c.c.  of 
the  filtrate.  For  the  examination  of  the  blood  a  little  of  the 
agar  solution  is  poured  on  to  a  slide  and  allowed  to  set.  After 
the  agar  is  quite  cold  a  strip  about  2  mm.  broad  is  cut  out  of  it, 
and  the  drop  of  blood  gained  from  the  finger  is  applied  to  this 
strip.     This  is  then  covered  with  a  cover-slip." 

The  amoeboid  movements  of  the  platelets  may  be  seen  by 
means  of  this  method,  and  they  can  thus  be  more  closely  studied 
than  in  any  other  way. 

With  regard  to  the  origin  and  significance  of  the  blood  plate- 
lets, the  majority  of  authors  (of  whom  Hayem,  Bizzozero,  Laker, 
and  Arnold  should  be  especially  mentioned)  have  come  to  the 
conclusion  that  they  are  preformed  in  living  blood.  The  author 
believes  that  this  view  is  correct.  The  opposite  view,  which  is 
held  especially  by  Lowit,  that  these  structures  are  formed  in  the 
blood  after  it  has  left  the  blood  vessels,  is  denied  by  the  author, 
on  the  ground  of  his  own  extensive  observations. 

Some  authors,  including  Deetjen,  Argutinsky,  and  others,  have, 
within  recent  times,  suggested  that  the  blood  platelets  should  be 
regarded  as  independent  complete  cells.  This  opinion  is  based  on 
the  generally  accepted  structure  of  the  majority  of  the  platelets, 
which  at  times  even  in  unstained  specimens  show  a  strongly 
refractile  internal  substance  and  a  less  strongly  refractile  external 
substance  ;  this  division  is  confirmed  by  the  tinctorial  behaviour 
of  the  elements.  The  internal  substance  stains  with  strong  basic 
dyes  and  when  nuclear  dyes  are  applied  in  strong  solution 
(Pappenheim). 

Morawitz  deduced  from  the  part  which  the  platelets  play  in 
the  coagulation  of  blood  (see  below),  and  from  their  thrombogen 


THE  BLOOD  PLATELETS:  H^^MOCONLV  205 

content  whioh  ])laceH  tluiin  in  a  (lif'ferfMit  cato^ory  to  all  other 
elements  of  the  hlood,  tli.'tt  tiiey  niuHt  ha  independent  cells. 

These  facts,  howc-vfir,  nvc,  insiidieient  to  show  that  the  platelets 
should  be  regarded  as  real  cells.  The  chief  objection  to  this  view, 
wliioh  has  been  held  by  other  and  especially  the  older  authors,  is 
an  observation  ol'  Schwalbe's.  lie  found  these  platelets  especially 
numerous  in  tied  vessels  between  the  two  ligatures. 

Whether  they  are  intravital  fragments  of  plasmatic  substances 
or  whether  they  are  cast  off  from  the  cells  cannot  at  present  be 
decided  witli  certainty,  even  if  there  is  reason  to  believe  that  the 
latter  view  is  probably  correct.  The  glycogen  content  of  the 
platelets  (see  p.  52)  certainly  suggests  that  they  are  derivatives 
of  the  blood  cells. 

Some  authors  believe  that  the  platelets  are  derived  from  the 
leucocytes  (F.  Mliller,  Arnold,  Grrawitz).  The  most  striking 
argument  against  this  supposition  is  the  fact,  which  was  demon- 
strated by  Helber,  that  in  the  blood  of  mammalian  embryos, 
platelets  can  be  found  before  the  leucocytes  have  been  formed. 
If  the  platelets  were  derived  from  leucocytes  it  would  be  necessary 
to  assume  that  they  are  formed  in  a  different  manner  during 
embryonal  life  than  during  post-embryonal  life,  or  that  a  second 
method  of  production  comes  into  force  after  birth. 

The  suggestion  that  the  blood  platelets  are  derived  from  the 
red  blood  corpuscles  receives  more  support  at  present  than  any 
other  suggestion.  There  are,  however,  three  different  conceptions 
with  regard  to  this  mode  of  origin. 

According  to  Arnold,  Schwalbe,  and  their  pupils,  both  pig- 
mented and  pigment-free  plates  originate  by  means  of  erythror- 
rhexis  and  erythroschisis.  G-reat  caution  is  necessary  with  regard 
to  the  acceptation  of  this  supposition,  since  it  is  scarcely  possible 
to  differentiate  between  schistocytes  and  platelets,  and  since  the 
complicated  structure  of  the  platelets  would  be  difficult  to  account 
for  if  this  were  true. 

The  last-mentioned  objection  would  also  apply  to  the  suggestion 
made  by  Weidenreich,  that  the  blood  platelets  are  detached  par- 
ticles from  the  surface  of  the  erythrocytes. 


206  ANiEMIA 

The  so-called  nucleoid  theoiy  appears  to  be  well  founded,  and 
is  supported  by  the  majority  of  htematologists.  According  to  this 
theory,  the  blood  platelets  owe  their  origin  to  the  remains  of 
nuclear  substance,  which  result  from  the  endo-corpuscular 
karyolysis  of  the  erythrocytes.  This  theory  has  recently  received 
considerable  support  from  the  observations  made  by  its  founder, 
Pappenheim,  with  the  assistance  of  the  dark  field  microscope. 
Blood  platelets  are,  according  to  this  theory,  nothing  else  than 
discharged  nucleoids.  One  or  two  very  striking  facts  speak 
greatly  in  favour  of  it.  These  include  the  staining  of  the  chro- 
matin and  also  direct  morphological  analysis.  Not  infrequently 
the  specimens  give  the  appearance  as  if  the  blood  platelets  com- 
pletely formed  were  issuing  from  the  bodies  of  the  red  blood 
corpuscles  (Koppe,  Engel,  Maximow,  Hirschfeld).  The  pictures 
seen  in  these  specimens  are  often  so  suggestive  that  Naegeli's 
objection  can  scarcely  lessen  the  likelihood  of  the  correctness  of 
the  doctrine.  Naegeli  was  of  opinion  that  the  specimens  seen  by 
him  were  merely  instances  of  blood  platelets  superimposed  on  the 
middle  or  edges  of  erythrocytes. 

A  view  which  is  held  by  a  number  of  observers  (Schwalbe, 
Grrawitz),  that  the  platelets  may  be  derived  from  various  sources, 
is  the  least  likely  of  all.  If  it  were  accepted  it  would  be 
necessary  to  give  up  regarding  the  platelets  as  uniform  elements 
of  the  blood. 

J.  H.  Wright  has  quite  recently  observed  tlie  production  of 
the  blood  platelets  in  bone  marrow  and  in  the  spleen ;  he  has 
seen  them  being  formed  by  detachment  of  the  plasma  of 
megakaryocytes. 

The  knowledge  possessed  at  present  with  regard  to  the 
physiological  function  of  the  blood  platelets  is  also  extremely 
defective.  The  original  view  which  was  put  forward  by  Hayem, 
that  the  platelets  are  the  precursors  of  the  red  blood  discs  and 
should  therefore  be  called  heematoblasts,  is  regarded  by  the 
majority  of  hsematologists  as  untenable.  On  the  other  hand,  the 
intimate  connection  between  the  blood  platelets  and  coagulation 
which    was    first   noticed   by  Bizzozero    has    been    recognised   in 


THE  IH.OOI)  lM>y\TRLETS:  HTRMOCOXIA  207 

iioai'ly  all  the  recent  works  on  tlic  Kuljject  (of.  JJiwit  and 
Schvvalbe's  reviews).  It  is  still  nnccrtain  wliethcr  tin;  substance 
of  the  platelets  yields  tlic  iniit(;iial  for  1,1k;  I'oiination  of  fibrin  as 
liizzozoro  suL!,'ii;osts,  oi'  wlietli(;i'  th(!y  onl)'  jdiiy  the  ])ait  of  inter- 
mediators, in  accordance  with  the  observations  of  Eljertii  and 
Schimnielbusch  on  the  formation  of  thrombi.  It  would  occupy 
too  much  space  to  enter  into  a  discussion  of  the  cbemical  aspect  of 
this  (juestion  in  this  ])la('.e,  and  for  this  reason  only  a  few  clinical 
observations  will  be  mentioned,  which  point  to  the  relations 
between  the  coagulability  of  the  blood  and  the  platelet  content. 

A  considerable  increase  of  blood  platelets  is  found  especially 
in  chlorosis  (Muir),  and  also  in  post-ha^morrhagic  ana-mia 
(Hayem).  In  both  these  conditions  there  is  a  marked  raising 
of  the  coagulability  of  the  blood.  An  important  observation 
of  Denys  should,  however,  be  mentioned,  who  found  that  in 
two  cases  of  purpura  the  only  morphological  change  of  the 
blood  was  a  very  considerable  decrease  of  blood  platelets.  It 
is  well  known  that  the  coagulability  of  the  blood  is  markedly 
diminished  in  purpura,  or  may  be  abolished  altogether.  Ehrlich 
also  was  able  to  examine  a  similar  case,  in  which  the  blood 
platelets  were  entirely  absent. 

A  number  of  authors  (Cesaris-Demel,  Hayem,  Levaditi, 
Eowley)  have  described  an  increase  in  volume  of  the  platelets  in 
various  ana:'mias,  while  Pappenheim  described  the  same  in  poly- 
globuhemia.  The  size  may  be  as  large  as  that  of  a  normal 
erythrocyte. 

Le  Sourd  and  Pagnier  have  suggested  another  method  of 
gaining  information  with  regard  to  blood  platelets.  By  injecting 
the  blood  platelets  of  rabbits  into  guinea-pigs  they  obtained  a 
serum  from  the  guinea-pig  which  was  capable  of  exercising  a 
specific  action  on  the  rabbit's  platelets.  This  serum  destroyed 
the  platelets  in  vitro,  and  in  the  body  of  the  living  rabbit  it 
caused  them  to  disappear  altogether  wdthout  in  any  way  damaging 
the  erythrocytes  or  leucocytes.  The  deduction  which  these 
authors  drew  from  these  experiments,  that  the  platelets  could  not 


208  ANEMIA 

be  derivatives  of  either  red  or  white  blood  corpuscles,  does  not 
appear  to  be  justified ;  it  could  be  assumed  that  the  platelets,  being 
the  products  of  disintegration,  would  possess  a  smaller  or  different 
kind  of  resistance  to  that  of  the  mother  cells. 

G-ruber  and  Futaki  extracted  a  substance  from  blood  platelets 
which  acted  bactericidally  against  tetanus.  Tschistowitsch  is 
inclined  on  the  strength  of  his  blood  platelet  counts  to  apply  this 
observation  generally,  and  to  regard  these  elements  as  being 
possessed  of  the  function  of  carrying  the  protective  substances  of 
the  blood. 

Ottolenghi  regards  the  blood  platelets  as  the  originators  of 
alexin,  because  he  ascribes  to  them  the  capability  of  reactivating 
donkey's  or  rabbit's  serum,  which  had  been  robbed  of  a  bacteri- 
cidal action  towards  tetanus  bacilli  by  heat. 


H.  F.  Miiller  has  described  a  fourth  element  of  blood,  and 
has  given  it  the  name  of  hsemoconia.  These  are  found  in  blood 
plasma  in  the  form  of  very  minute,  colourless,  highly  refractile 
corpuscles,  like  granules  or  cocci.  They  are  possessed  of  active 
molecular  movement,  which  can  be  watched  for  a  very  long  time 
without  any  special  precautionary  measures.  They  do  not  turn 
black  with  osmic  acid  (Miiller),  and  therefore  do  not  contain  fat. 
They  do  not  appear  to  have  any  connection  with  the  formation 
of  fibrin,  since  they  are  always  found  outside  the  fibrin  network. 
Miiller  found  them  in  every  specimen  of  normal  blood,  but  noted 
that  their  number  varied  very  considerably.  They  were  very 
markedly  increased  in  number  in  one  case  of  Addison's  disease, 
and  diminished  in  starvation  and  in  cachexia. 


BIBLIOGEAPHY. 

Argutinsky,  quoted  by  Naegeli,  Anat.  Anzeiger,  1901,  vol.  xix.  No.  21. 

Arnold. — "Zur  Morphologie  und  Biologie  der  roten  Blutkorperchen," 
Firchow's  Archiv,  1896,  vol.  cxlv.  "  Ueber  die  Herkunft  der  Blutplatt- 
cLen,"  Zentralhlf.  allyein.  Pathol,  und  pathol.  Anat.,  1897,  vol.  viii. 


THE  BLOOD  PLATELETS:  Ilyl^MOCOX  L\  20'.) 

Bl/ZOZKRO.      "  IJelicn'  ciiieii   iicmn    l<'()iiiilM--l;ui'lliil   '\''H   ]'A\iU'H  iiikI  dcHseii 
Rolle  Ix'i   (Icr    Tlimniliosc    unil    ili-i-    l;liil;.n-riiiiiiMi^',"    Virrhow'ti  Archiv, 
1882,  vol.  xc. 
Brodik  and  Kusskll.  — " 'I'Ik;   luimiicnili'in   of    JJlood    I'laleletK,"  Journ.  of 

Fhy.Hiolufjy,  1897,  Noh.  4  iuul  T). 
BiJiiKEK. — M/inchen.  wed.  lVochev!!r}i.r.,  1004,  No.  27. 
Cbsakis-Demel.— "]jC!ol)aclitiing(!ii  iiln-r  das   Blul,"  />«  SperwuiUali,  1905^ 

vol.  lix.  ((luoted  in  FoL  Juion.,  1900). 
Deetgen. — "  IJntersuclnin;^  iibci' ilic  I'-lul  plat  Iclu.-ii,"  I'irchovh  Arrhiv,  1901, 

.     vol.  clxlv. 
Denys. — "Un  noiiveau  cas  de    Purpura  avec  diminution   conaiderable  des 

plaquette.?,"  Revue  La  Cellule^  vol.  v.  part  1. 
Enqei.,    C.    S. — Leitfaden    zur     klinisrhen     Untersurhamj     den     Jllutes,    3rd 

Edition,  Berlin,  1908. 
Grawitz. — Klinische      Pathologic     des      Bluies,      3rd      Edition,      Leipzig, 

190G. 
Gruber  and  Futaki. — "  Ueber  die  Resistenz  gegen  Milzlirand  und  iiber  die 
Herkunft  der  milzbrandfeindliclien  Stoffe,"  Milnchen.  med.  JFochenschr., 
1907,  No.  6. 
Hayem.— -Dtt  sang,  Paris,  1889. 
Helber. — "Ueber  die  Entstehung  der  Blutplattcben,"  u.s.w.,  Deutsch.  Arch. 

f.  Min.  Medizin,  1905,  vol.  Ixxxii. 
Hirschpeld.— "  Demonstration  mikroskopischer   Blutphiparate    und   Blut- 
plattcben," Ver.f.  innere  Medizin,  February  4,  1901. 
Kemp,  Catham,  and  Harris.—"  The  Blood  Plates  ;  their  Enumeration  in. 
Physiology  and  Pathology,"  Journ.   of  the  Amer.  Med.  Assoc,  April  7^ 
1906  (quoted  in  Fol.  haem.). 
Laker. — "Die    Blutscheiben    sind    konstante    Formeleniente    des    normal 

zirkulierenden  Saugetierblutes,"  Virchoio's  Archiv,  1889,  vol.  cxvi. 
Levaditi,  qrioted  by  Schwalbe. 

Maximow.— "  Ueber  die  Struktur  und  Entkernung  der  roten  Blutkorperchen 
der  Siiugetiere  und  die  Herkunft  der  Blutplattcben,"  Archiv  f.  Anat. 
u.  Enticickhmgsgesch.,  1899. 
MuiR,  E.— "  Contribution  to  the  Physiology  and  Pathology  of  the  Blood,"^ 

Journ.  of  Anat.  and  Physiol,  1891,  vol.  xxv.  p.  475. 
Muller,  H.  F.— "  Ueber  einen  bisher  nicht  beachteten  Fornibestandteil  des 

Blutes,"  Zentralbl.f  allgem.  Pathol,  und  pathol.  Anat.,  1896,  p.  929. 
Naegeli. — Blutkrankheiten  und  Blutdiagnostik,  Leipzig,  1907. 
Ottolenghi.— "  Die     Blutplattcben     als    Alexinerreger,"     Miinchen.     m^d. 

TVochenschr.,  1907,  No.  17. 
Pappenheim.— "Dunkelfeldbeleuchtung,"  Fol.  haem.,  1908,  vol.  vi.  p.  190. 
"  Demonstration  von  Blutplattcben,"  Milnchen.  med.  JVochenschr.,  1901,. 
No.  24,  p.  989. 
Rosin  and  Bibergeil.— "Ueber  vitale  Blutfiirbung,"  u.s.w.,  Zeitschr.f.  khn. 

Medizin,  1902,  A'ol.  liv.  (Bibliography). 
Rowley.— "  Note   on   the   Morphologie   of    Blood  Plates,"  Journ.  of  Amer. 

Med.  Assoc,  March  10,  1906  (i'oZ.  haem.). 
S&-Bhi.--Klinische  Untersuchungsmethoden,  4th  Edition,  Leipzig,  1905. 

14 


210  ANEMIA 

ScHiMMELBUSCH. — "  Die   Blutplattclieu  und  die  Blutgerinnung,"  Virchow's 

Archiv,  1885,  vol.  ci. 
ScHWALBE.— t"  Thrombose,    Gerinnung,  Blutplattclien,"  Liibarscli-Ostertag's 

Ergebnisse,  1907. 
SouRD,  Le,  acd   Pagniez. — "Recherches   experimentales   sur   le    role   des 

hematoblastes  dans  la  coagulation,"  Compt.  rend.  Soc.  de  Biol.,  1907,  vol. 

Ixii.  p.  934. 
TscHiSTOWiTSCH. — "  Ueber   die  Blutplattchen  bei  akuten  Infektionskrank- 

heiten,"  Fol.  haem.,  1907,  No.  3. 
Wright,  J.   H. — "  Die  Entstehung  der   Blutplattcben,"    Virchow's  Archiv, 

1906,  vol,  clxxxvi. 


DESCRIPTION    OF    PLATES 

DESCRIPTION  OF  PLATE  I 

(Magnification,  700   1)iamkter,s) 

1-6. — Myeloblasts  (Gieinsa  staining). 

Cells  1-3  are  from  a  case  of  chronic  myeloid  leuktemia. 
Cells  4-6  from  a  case  of  acute  myeloid  leukiumia. 

The  nucleus  corresponds  to  the  nucleus  of  a  myelocyte,  .showing 
a  delicate  chromatin  structure  and  three  or  four  distinct  blue 
nucleoli.  The  protoplasm  pos.sesses  a  basophile  reticulum,  reach- 
in  i,^  right  up  to  the  nucleus.     There  are  no  granules. 

7-9.— Development  of  Myeloblasts  to  Neutrophile  Myelo- 
cytes (Giemsa). 

Cell  7  (chronic  myeloid  leuka?uiia).  The  reticulum  is  .still 
markedly  basophilic ;  there  are  but  few  granules,  and  the 
nucleoli  are  still  visible. 

Cell  8  (chronic  myeloid  leukaunia).  Similar  to  Xo.  7.  The 
nucleoli  are  still  distinct,  but  the  granulations  are  more 
plentiful. 

Cell  9  (another  case  of  chronic  myeloid  leuktemia).  Xo 
nucleoli  are  visible  ;  the  granulation  is  very  sparse. 

10-17. — Neutrophile  Myelocytes  (Giemsa). 

Cells  10-14  and  17  are  from  cases  of  myeloid  leukfemia. 
Cells  15-16  are  from  croujaous  pneumonia. 

The  granules  are  very  numerous.  The  basophilic  character  of 
the  protoplasm  has  diminished. 

Cell  17,  slightly  crushed  (demonstration  of  isolated  granules). 

18. — Metamyelocytes  (Leuksemia)  (Giemsa). 

Transition  of  myelocyte  nucleus  to  polymorphous  form. 

19-25. — Polym.orpho-nuclear  Neutrophile  Leucocy-tes  (Giemsa). 

Normal  blood  and  leucocytosis. 
Cell  25  crushed  (isolated  granules). 

26-30. — Eosinophile    Myelocytes    (Giemsa).      From    two    cases    of 

chronic  mveloid  leukaemia. 

211 


212  DESCRIPTION  OF  PLATES 

Cell  26. — Nearly  all  tlie  granules  are  blue  (basopliile  pre- 
liminary stage).      At  the  edge  some  red  granules  are  seen. 

Cells  27-28  and  30  (crushed).  The  red  granules  are  pre- 
dominating ;  only  a  few  blue  granules  are  present. 

Cell  29. — All  the  granules  are  red  (oxyphil e,  ripe),  but  the 
protoplasm  is  distinctly  reticulated  blue. 

31-35. — Eosinophile  Leucocytes  (Giemsa). 

Cell  31. — Metamyelocyte  from  a  case  of  myeloid  leukaemia. 
The  nucleus  is  just  taking  on  the  polymorphous  structure. 
Cell  25  (crushed).     Showing  isolated  granules. 

DESCRIPTION    OF   PLATE   II 

(Magnification,  700  Diameters) 

36-43. — Mast  Myelocytes  (Giemsa).  From  a  case  of  chronic  myeloid 
leuksemia  with  very  numerous  mast  cells. 

Cell  36. — The  blue  precursors  of  the  mature  granules  are 
differentiated  in  the  protoplasm. 

Cell  37. — Numerous  blue  granules. 

Cells  38-40. — A  mixture  of  immature  blue  and  mature  mauve- 
coloured  granules. 

Cells  41-42. — Mauve-coloured  granules, — markedly  resistant 
to  water. 

Cell  43. — Mature  mauve-coloured  granulation ;  no  longer 
resistant  to  water. 

44. — Mast    Cell    Myelocyte   (Giemsa).      Prom    case    of    myeloid 
leuksemia. 

45-48. — Mast  Leucocytes  (Giemsa). 

The  granules  are  readily  soluble  in  water. 

Cells  45-46. — Normal  blood. 

Cells  47-48. — Chronic  myeloid  leuksemia. 

49-51. — Mast  Leucoc3rtes  (May  Griinwald  staining).     From  a  case  of 
myeloid  leuksemia. 

52-57. — Large     Mononuclear     Leucocytes     and     Transition 
Forms  (Giemsa). 

ISTormal  blood  and  leucocytosis.  The  granulation  is  very  fine 
and  plentiful,  and  the  protoplasm  slate  coloured.  The  series 
shows  a  gradually  increasing  transformation  of  the  nucleus.  The 
much  more  intense  nuclear  staining  and  the  much  finer  granu- 
lation than  in  the  myelocytes  should  be  noted. 

58-62. — Stimulation  Forms  =  Pathological  Myeloblasts  (Giemsa). 

Vacuoles  in  the  deep  blue  protoplasm. 

Cells  58-59. — From  a  case  of  pernicious  anaemia. 

Cells  60-62. — From  a  case  of  encephalitis  (child  aged  six  years). 


DESCJlirTION  OF   IM.AIKS  2J3 

63-87. — Lymphocytes  (fJioniH.'i). 

Cki:i,s  ()3-(;0.     Normal  Ijlood,  C/.i-C)!')  witlioiif,  ;izur(;  granules, 

GH-nii  wiLli  ;i/,iin;  gnumles. 
(.\;]\  G'J  HOiiicwhiit  crushed. 

Cklls  70-72. — SoiiH'wliat,  l;irf,'or  l^iiipliooyteH  (four  years'  old 

cl.ild). 
CiOLLS  73-87. — ^Lynipliocylcs  irDiii  a  case  of  lyuijdiaLic  louk;x;niia. 
Ckt.lh  73-75. — Nucleus  almost  free. 
Cklls  76-81. — Large  forms.     78  cruslied.     70-81  with  azure 

granules. 
Cklls  82-87. — Transformation  of  nucleus  into  Rieder's  form. 


DESCRIPTION    OF   PLATE   III 

(Magnification,  700  Diameters) 

88-97. — Erythroblasts   (Giemsa).     From   a  case  of   carcinoma  of   the 
bone  marrow. 
Cells    88-90. — Megaloblasts,    showing    polychromatic    proto- 
plasm. 
Cells  91-93. — Intermediate  forms  between  megaloblasts  and 

normoblasts  ;  two  are  almost  orthochromatic. 
Cells  94-95. — Polychromatic  and  orthochromatic  normoblasts. 
Cells  96-97.- — Dissociation  of  nucleus  in  polychromatic  and 
basophilic  granulated  cells. 

98-1 05.— Erythrocytes  (Giemsa). 

Megalocytes  and  normocytes  in  all  stages  from  marked  poly- 
chroniasia  up  to  orthochromasia.  Case  of  carcinoma  of  the  bone 
marrow. 

106-118.— Mitosis  of  Erythroblasts  (Giemsa). 

All  the  cells  possess  characteristic  basopliile  granulation  of  the 
protoplasm. 

Cells  106-115. — All  stages  of  mitosis,  from  a  case  of  infantile 

pseudo-leuksemic  ansemia. 
Cells  116-118.— A  typical  pathological  mitosis,  from  a  case  of 

acute  myeloid  leuktemia. 
Cell  118.— Triple  mitosis  and  triple  division  of  the  nucleus. 

119-122.— Remains  of  Nuclei  and  Nuclear  Debris  (Giemsa).    From 
a  case  of  infantile  pseudo-leukaemic  ansemia. 
Cells  119-121. — Solution  of  the  nuclear  remains. 

123-142.— Ring  Bodies  (Giemsa).     At  times  with  red  or  blue,  or  red  and 
blue  granulations.      The   rings   are   in  part  free  in.   the 
plasma. 
Cells  123-134. — From  a  case  of  pernicioiis  anremia. 


214  DESCRIPTION  OF  PLATES 

Cells  135-142. — From  a  case  of  acute  myeloid  leukaemia. 

By  an  unfortunate  mistake,  ^vhicll  could  not  be  corrected  after 
it  was  discovered,  tlie  cells  of  the  series  88-93,  as  well  as  cells 
102  and  103,  were  reproduced  on  a  smaller  scale  than  in  the 
drawings.  This  reduction  is  considerable  and  likely  to  mislead. 
The  diameter  of  the  cells  should  be  about  one-third  larger  than 
they  appear. 

DESCRIPTION   OF   PLATE   IV 

(Magnification,  700  Diameters) 

143-156. — Red  and  Blue  Punctation  in  Erythrocytes  (Giemsa). 
Cells  143-153. — From  cases  of  pernicious  ansemia. 
Cells  154-156. — From  cases  of  acute  myeloid  leukaemia. 

A  mixture  of  the  blue  and  red  punctation  is  at  times  seen, 
while  at  other  times  only  the  red  appears.  Two  cells  show  a. 
diffuse  red  coloration  of  the  protoplasm.  The  size  of  the  red 
granules  varies  at  times. 

157. — Red  Punctation  in  Erythrocytes  (Giemsa).    From  a  case 
of  pernicious  anaemia. 

The  cells  show  very  well-marked  red  granules,  singly  or  in 
numbers.  In  the  middle  there  is  a  polychromatic  megalocyte 
with  numerous  red  granules. 

158-169. — Blue  Basophile  Punctation  (Giemsa). 

Lead  poisoning.     All  the  cells  depicted  are  orthochromatic. 

Cells  163-169. — Severe  chlorosis  in  the  stage  of  recovery. 

There  are  numerous  iDolychromatic  cells  with  blue  basophile 
punctation.     One  red  grain  is  also  seen. 

DESCRIPTION    OF   PLATE   V 

(Magnification,  700  Diameters) 

170. — Blood  Platelets  (Giemsa).     From  the  blood  in  chlorosis. 
a-g.  Cells  stained  by  Triacid  Solution. 

(a)  Neutropliile  myelocytes. 

(b)  Polynuclear  neutropliile  leucocytes. 

(c)  Eosinophile  cells. 
{d)  Mast  cells. 

(e)  Normoblasts. 
(/)  Megaloblasts. 
(g)    Erythrocyte.s. 

The  illustrations  1-170  have  been  drawn  in  colours  by  the 
academie  painter,  Mr.  L.  Schrotter  (Zurich-Heidelberg),  from 
preparations  supplied  by  Dr.  Naegeli,  and  under  his  supervision. 


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INDEX 


Acid  dyes,  41. 

„    fuchsin,  42,  43. 
Acidopliile  granules,  41,  46. 
Adventitial  cells,  149,  150. 
Alcohol  fixation,  38. 
Alkali  in  blood,  25,  26,  53. 
Altmann  -  Schridde's     granules,    91, 
102,  136. 
„  ,,  stain,  91. 

Anaemia,  definition  of,  1. 

„       pernicious,    27,  63,  66,  67, 
69,  76,  79,  100,  175. 
"  Ancestor  "  corpuscles,  69. 
Anisocytosis,  67. 
Ankylostonium  ansemia,  78. 
Amethyst  violet,  42,  43. 
Asthma,  165,  171. 
Aurautia,  37,  40. 
Autolysis,  96. 
Azure,  45. 
Azurophile  granules,  102,  105. 

Basic  dyes,  41. 

„     staining  (double),  47. 
Basophile  granules,  47,  49. 
„         mast  cells,  125. 
Biermer's    anaemia,   27,  63,   66,    67, 

69,  76,  79,  100,  175. 
Bioblast  theory,  141. 
Bismarck  brown,  41. 
Blood  platelets,  38,  52,  202-207. 
Bone  marrow,  109,  124. 
Bothriocephalus  ana3mia,  78,  172. 
Bremer's  diabetes  reaction,  54. 
Bronchial  asthma,  165,  171. 

Carcinoma,  75. 
Carmine,  40. 


Chemutaxis,  121,  129,  145,  154,  157, 

159,  171. 
Chenzinski's  solution,  38,  44,  48. 
Chromic  green,  41. 
Chronic  nephritis,  75. 
Climate,  influence  of,  on  blood  cells, 

8,  9,  12. 
Coagulability  of  blood,  3,  22,  26,  27, 

•206,  207. 
CO  hseraoglobin,  4,  5. 
Colour  index,  17. 
"Combined"  staining,  39,  41. 
Cover  glasses,  33-35. 
Cresyl  violet  R,  98. 

Dahlia  glycerin,  202. 
Dark  field  illumination,  31. 
"  Dedifierentiation,"  151. 
Definition  of  anaemia,  1. 
Diabetes  reaction  (Bremer),  54. 

„  „         (Williamson),  5.i. 

Differential  staining,  37. 
Discoplasm,  56,  68. 
Double  basic  staining,  47. 
Dry  films,  32-35. 

„     substance  in  blood,  11. 
Dualistic  doctrine,  146. 
Dye  mixtures,  neutral,  42. 
Dyes,  acid,  41. 
„      basic,  41. 

Eatin,  98. 

Electric  discharge,  effect  on  blood,  28. 
Eosin,  44,  46,  48,  49,  203. 
Eosin-aurantia-nigrosin  mixture,  37. 
Eosin  and  heematoxylin,  46. 
Eosinophile  cells,  97,  113,  125,  164, 
165,  173,  183,  184. 


216 


INDEX 


Eosinophile  granules,  49,  97,  145. 

,,       mononuclear  cells,  182, 183. 
„  ■     myelocytes,  100. 
Eosinopliilia,  compensatory,  168. 
„  leuksemic,  169. 

„  nervous,  169. 

„  medicamentous,  169. 

„  scarlatinal,  169. 

„  post-infective,  167. 

Erythroblasts,  71-73. 
Erythrocytes,  3,  6,  7, 17,  18,38,  48,  56. 
,,  nucleated,  60,  68,  69, 

70,  115,  190-192. 
„  origin  of,  71,  72. 

,,  punctated,  61-64,  66. 

Erythropoiesis,  124. 
Estimation   of  hsemoglobin  content, 

13-15. 
Ej^e-pieces  (microscope),  32. 

Films,  dry,  32-35. 

Fixing  by  heat,  37. 

Fixation  of  films,  36. 

Formal  fixation,  38. 

Fuchsin,  41-43. 

Fuchsinophile  granules,  91,  102,  136. 

Giemsa's  stain,  38,  50,  93,  94. 

Gigantoblasts,  69. 

"  Globules  nuclees  geantes,"  69. 

"  Globules  nuclees  de  taille  moyenne," 

69. 
Glycogen  in  blood,  52. 
Granules,  62,  110,  133-135. 
Granules,  acidophile,  41,  46. 

„         Altmann's,  91,  102,  136. 

„        azurophile,  102. 

„         basojihile  47,  49. 

„         eosinophile,  49,  97,  145. 

„         fuchsinophile,  91,  102,  136. 

,,         metachromic,  107. 

„         neutrophile,  43,  94,  96,  99, 
141-143,  188. 

„         perinuclear,  96. 
Guinea-pig's  blood.  111. 

Hsemacytometer,  5,  10. 
Hfematoxylin,  38,  39,  46. 


Haemoconia,  208. 

Hfemoglobin,  2,  4,  5,  11,  13,  20,  24, 

41,  57,  58. 
Hsemoglobinsemia,  76. 
Heemoglobinometer,  14,  15. 
Hgemometer,  14,  15. 
Hsemorrhage,  22,  63. 
Haldane's      and      Lorrain  -  Smith's 

method       of       determining       the 

quantity  of  blood,  4,  5. 
Hayem's  fluid,  6. 
Helminthiasis,  166,  172. 
Hygrometry,  22. 

Indacine,  42. 
Iodide  of  eosin,  53,  203. 
Iodine  test  for  glycogen,  52. 
lodophile  substance,  96. 
Iron  in  blood,  16. 

Jenner's  stain,  50,  98. 

Karyolysis,  72,  74. 
Karyorrhexis,  72,  74. 
Kottmann's  method   of  determining 
the  quantity  of  blood,  4. 

Lead  poisoning,  63. 

Leucocytes,  30,  87,  151-155, 157,  158. 

,,  large  mononuclear,  94,   . 

,,  polynuclear,  95,  126. 

,,  transition  form,  94,  95. 

Leucocytosis,  30. 

,,  mast  cell,  175. 

„  pathological,  161-164. 

„  physiological,  161. 

,,  polymorpho-nucl ear  neu- 

trophile,   30,  89,   160, 
164. 

,,  polynuclear    eosinophile, 

164. 
Leucopenia,  154,  158. 
Leukfemia,    30,    69,    73-75,    89,    106, 

163,  176-193. 
Lymphsemia,  132. 
Lymphatic  glands,  109,  116,  117. 
Lymphatic  leukgemia,  177-180. 

„  system,  146. 


INDEX 


217 


Lymphatic  tissue,  101,  103. 
Lympliocytcs,  87,  88,  90. 

„  (pathological),  105. 

Lymphocytosis,   114,    117,    120,    121, 

130,  131. 
Lymphocytoiuatosis,  119. 

Malignant  disease,  75. 
Mast  cells,  47,  98,  175,  185. 

„  basophile,  125. 

Mast  myelocytes,  101. 
Mav-Griinwald's  stain,  49. 
Megaloblasts,  70,  71,  75-77,  79. 
Megalocytes,  67. 
Metrachroniasia,  98. 
Metachromic  granulation,  107. 
Methylene-blue,  41,  43,  44,  48,  137. 
,,  blue-azure,  45,  50. 

„  blue-eosin,  44,  48,  50. 

Methyl-green,  41-43,  91. 
Methyl- violet,  41. 
Microblasts,  70. 
Microcytes,  38,  67. 
Mitosis,  11,63,  65,  180,  186. 
Mononuclear,  large  leucocytes,  94. 

„  cells  with  neutrophile 

granules,  99. 
,,  eosinophil  e  cells,    182, 

183. 
„  cells   (non-granulated), 

125. 
Morawitz's   method   of    determining 

the  quantity  of  blood,  4. 
Mlillern's  staining.  49. 
Myeloblasts,  101,  103. 

„  (pathological),  104. 

Myelocytes,  99,  137,  138. 

„  eosinophile,  100. 

Myeloid  leukeemia,  178,  180,  181. 
Myeloid  tissue,  103,  146,  147. 

Narcein,  42,  43. 
NegatiA'e  nuclear  staining,  54. 
Neutral  mixtures  of  dyes,  42. 
Neutral  red,  137-139. 
Neutrophile  cells,  108. 
Neutrophile  granules,  43,  94,  96,  99, 
141-143,  188. 


NikiforolfH  fi.xution,  38. 
Normoblasts,  69,  71,  74,  76,  77. 
Normocytes,  67. 
Nucleated   erythrocytes,   60-69,    70, 

115,  190-192. 
Nuclei  of  lyiiipljocyti;H,  91. 

Oikoid,  56. 
Oligochromscmia,  2. 
Oligocythtcniia,  2. 
Orange  G,  42,  43. 
Origin  of  leucocyte.",  109. 
Oxygen,  12. 
Ozonophores,  141. 

Pacini's  fluid,  6. 

Panoptic  staining,  39. 

Pappenheim's  mixture,  48. 

Pathological  leucocytes,  161-164. 

Pathological  lymphocytes,  105. 

Pathological  myeloblasts,  104. 

Perinuclear  granules,  96. 

Pemphigus,  166,  173. 

Pernicious   anaemia,    27,    63,  66,   67, 
69,  79,  100,  175. 

Phagocytosis,  153. 

Physiological  leucocytes,  161. 

Phosphorus  poisoning,  75. 

Picrate  of  ammonium,  40,  42. 

Picro- carmine,  40. 

Plasma  cells,  106. 

Plasmodia,  40. 

Platelets     (blood),     38,      52,     202- 
207. 

Pletch's  method    of  determining  the 
quantity  of  blood,  4. 

Poikilocytosis,  11,  67,  77. 

Polychroniasia,  66. 

Polychromatic  staining,  41. 

Polychromatophilia,  58-60. 

Polycytheemia,  5,  8. 

Polymorpho-nuclear  neutrophile  leu- 
cocytes, 95,  126. 

Polymorpho-nuclear  leucocytosis,  30, 
8*9,  160,  164. 

Polynuclear    eosinophile    leucocytes, 
164. 

Pseudo-eosinophile  cells,  112,  126. 


218 


INDEX 


Punctated  erythrocytes,  61-64,  66. 
Pyronin,  41,  48,  91. 

Quadratic  ocular  diaphragms,  32. 
Quantity  of  blood,  3,  4. 
Quincke's  method  of  determining  the 
quantity  of  blood,  3. 

Keaction  of  blood,  24,  25. 
Eed   blood   corpuscles,  3,  6,  17,    18, 
38,  48,  56. 
,,  nucleated,  60, 

"  68,    69,    70, 

115,      190- 
192. 
origin  of,    71, 
72. 
,,  punctated,  61- 

"  64,  66. 

site  of  produc- 
tion,      124, 
125. 
size  of,  57. 
Ehodamin,  42. 
Kieder's  cells,  88,  91,  105. 
Eomanowsky's  dye,  44,  93. 
Eosanilin  picrate,  42. 

Schistocytes,  68. 

Separation  of  serum  from  clot,  27. 

Simultaneous  staining,  39,  41. 


Size  of  blood  corpuscles,  18. 

Size  of  red  blood  corpuscles,  57. 

Skin  diseases,  161. 

Slides,  35. 

Specific  gravity  of  blood,  11, 19-21,  29. 

Spleen,  108,  111. 

„        removal  of,  113. 
Spodogenous  tumours,  115. 
"Stimulation"    form   of   corpuscles, 

104. 

Tarchanoff' s  method  of  determination 

of  the  quantity  of  blood,  3. 
Thrombogen,  204. 
Tonicity  of  blood,  27. 
Transition  forms  (leucocytes),  94,  95. 
Triacid  staining,  46,  103. 

Urticaria,  176. 

Victor  Mayer's  apparatus,  37. 
Vital  staining,  51. 
Volume  of  erythrocytes,  22,  23. 
Volume  of  the  blood,  3,  4. 

White  blood  corpuscles,  30,  87,  151- 

155,  157,  158. 
Williamson's  test,  55. 

Ziemann's  solution,  49. 
Zooid,  56. 


Printed  hy  Morrison  &  Gibb  Limited,  Edinburgh 


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